Inspection on 05/09/06 for 429 Warwick Road

This inspection was carried out on 5th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

429 Warwick Road 13/09/07

429 Warwick Road 16/02/06

429 Warwick Road 10/08/05

429 Warwick Road 11/02/05

429 Warwick Road 28/04/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Warwick Road, 429 Solihull Birmingham West Midlands B91 1BD Lead Inspector Kerry Coulter Key Unannounced Inspection 5th September 2006 12:30 Warwick Road, 429 DS0000004512.V308086.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 Warwick Road, 429 DS0000004512.V308086.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. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warwick Road, 429 Address Solihull Birmingham West Midlands B91 1BD 0121 704 4563 F/P 0121 704 4563 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) Milbury Mrs Sue Kiely Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th February 2006 Brief Description of the Service: 429 Warwick Road is registered to provide accommodation and care for a maximum of 7 adults with learning difficulties. The home is situated on a main road with its own small car park at the front of building. The home is a large attractive modern building in keeping with the design of other houses in the neighbourhood. Bedrooms are situated on both the ground floor level and the upper floor of the home. Whilst the dimensions of the hallways and the staircase to the first floor make the house unsuitable for wheelchair users, the bedrooms on the ground floor levels provide a suitable living situation for some service users with minor / moderate mobility related needs. The home provides care to male and female service users , primarily in the middle age range. During the week service users are encouraged to make use of Day Service provision although service users often spend sometime at home. The home is situated within reasonable distance of shops and local amenities and the service has its own vehicle to support residents to access the community. The CSCI inspection report is available in the home for visitors to read if they wish to. The current scale of fees charged is £911 plus a contribution to the cost of the vehicle. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home, pre inspection questionnaire and reports from the provider. The unannounced fieldwork visit was carried out over six hours. This was the homes key inspection for the inspection year 2006 to 2007. The Manager and the staff on duty were spoken to. Due to the communication difficulties of some of the service users who live at the home they were not all able to give their views of the home, but the Inspector had the opportunity to meet with all service users. A tour of the premises took place. Care, staff and health and safety records were looked at. Two comment cards were received from relatives of service users about their views of the home, four comment cards were received from health and social care professionals. What the service does well: The Home is generally well run, and the style of management is relaxed, open and inclusive. It is a strength of this home that many of the staff have worked there for some time, service users are therefore supported by staff who know them well. Most of the staff have achieved an NVQ in care ensuring that they have the skills they need to meet the needs of service users. Service users participate in a variety of activities to include visits to pubs, cinema, meals out and walks. Staff at the home complete a monitoring form at the end of each month regarding the type and frequency of activities participated in by service users. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. Service user bedrooms are well maintained and personalised. The systems for the safe storage, handling and administration of medication were well managed so that service users receive the medication they need safely. Service users can choose what they eat and drink. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 6 Service users are supported by staff to maintain relationships with relatives and friends. The required recruitment checks are done to make sure that the staff are suitable to work the service users. Staff are well supported in their job role. Satisfactory systems are in place to ensure the health and safety of service users. What has improved since the last inspection? Clear efforts have been made by the Manager to meet requirements made at the time of the last inspection. The Manager is in the process of developing an information folder for service users and a separate one for visitors. Good work has been done to develop care management practice: statements of need continue to be updated, and care plans continue to develop. Some good work has been done on involving service users in the planned development of a sensory garden. Some service users bedrooms have been redecorated making them more personalised. Menus have been developed so that they are available in a picture format, making them easier to understand for service users. Two staff have been on a nutrition course. The Manager said this course had been really useful in helping to plan healthy menu’s. Progress has also been made on recruiting male staff, the home has one male casual staff and a new permanent male staff is due to commence soon. This will give the service users more choice on the gender of the staff they wish to support them. Service users are now not having to pay for staff expenses when they are accompanied on activities. Staff were working on their own development plan for the home in consultation with the service users. Some good work has commenced to seek the views of service users. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 7 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. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The Service User Guide provides prospective service users with relevant information about the home to enable them to make an informed choice about if they want to live there. The admissions procedure is satisfactory, prospective new service users have the opportunity to visit the home and assessment is completed. EVIDENCE: It was observed that the Statement of Purpose and Service User Guide documents are readily available in the home. The Service Users Guide is in an easy read format that includes pictures making it easier for service users to understand. Service users have a copy of the Guide in their care plan. The Manager is also in the process of developing an information folder for service users and a separate one for visitors, this currently includes a copy of the guide and additional information on the admission and complaints procedures as well as information about the Commission for Social Care Inspection. No new service users have moved into the home since the last inspection. The admissions procedure was sampled and was observed to be satisfactory. The Manager said that assessments would be completed prior to a new service user being admitted to the home, followed by an initial review after four weeks, Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 10 with a final review three months after admission to ensure that the service user had settled into the home. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need to support service users to meet their needs. Service users are supported to make decisions about their day-to-day lives. Service users are supported to take risks within a risk assessment framework. EVIDENCE: The care plans for two service users were sampled. Plans sampled had been reviewed in the last six months. The plans sampled detailed the support needs of individuals. Service users records indicate that needs are reviewed, using Individual Programme Planning (IPP) paperwork, involving day services staff and relatives every 12 months. Actions and goals are agreed at the meeting but it is recommended that the system for identifying a timescale for actions and who is responsible for ensuring they are carried out is improved. Lots of work is in process to develop the care plans to make them more service user focused and individualised. A copy of the plan had been developed for service users using a picture format. Each page had lots of small pictures and Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 12 was a little confusing, it would be better if there were fewer pictures on each page so each picture could be bigger making it easier for service users to understand. Some of the service users files needed a little tidying up, to ensure all the information was current. For example, one file contained behaviour guidelines dated 1998. The Manager and Deputy Manager both confirmed these guidelines were no longer in use. Service users are encouraged as far as possible to make decisions about their lives, this is done through regular residents meetings, attendance at reviews and 1:1 consultation. Sampling of resident meeting minutes indicate that topics of discussion include choice of activities, menu planning, CSCI inspection outcomes and staff recruitment. The Manager said that it is hoped in future that the minutes of these meeting will be made available to service users in a picture and photograph format. Service users spoken with confirmed they were involved in making decisions. Some good work has been done on involving service users in the planned development of a sensory garden. Staff have worked with service users on producing a collage on what they think it should look like. Service user records included individual risk assessments. These detailed how staff are to support the individual to minimise the risks involved. Risk assessments had been regularly reviewed and updated where there were changes to ensure that the current risks to the individual were fully assessed. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements generally ensure that people living at the home experience a meaningful lifestyle. EVIDENCE: All service users attend day service provision provided by Solihull Borough Council, including Parkview day centre. Encouragement is provided for service users to take part in many aspects of daily living, such as cleaning and tidying and shopping for personal items. It is an area of good practice that staff at the home complete a monitoring form at the end of each month regarding the type and frequency of activities participated in by service users. Records show that activities participated in have included shopping, pub visits, church, clubs, cinema and bowling. Opportunities are available to undertake activities on an individual basis as well as part of a group. One male service user has recently requested to start going swimming. The Manager said that female staff had offered to take this service user swimming but he had declined. To facilitate this activity the home has recruited a male staff who will be starting work Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 14 soon. Service users are consulted about what activities they want to do at the service user meetings. During the visit the Manager was showing one service user a leaflet about ‘The Horse of the Year’ show and asking him if he would like to go. Service users spoken with said that they were happy with the activities on offer. It was evident from talking to both service users and staff that service users are supported to maintain contact with their family and friends. Records evidence that relatives are invited to annual reviews and kept informed of the receipt of CSCI reports. Information for visitors to the home was observed to be on display in the hallway, this was in both a written and symbol format. Two comment cards were received from relatives of service users. These recorded that they were welcome at the home at any time and were able to meet in private with their relative. There was no evidence of strict house rules. Staff were observed sitting and socialising with service users. Service users are able to choose whether or not to spend time with others, or to have private time in their own rooms. The rights of service users were respected by staff. The evening meal was observed. Food looked appetising and nutritious, it was good that not all service users had exactly the same meal, this shows choice is available. Service users spoken with commented that they liked the food provided and confirmed that choice was available. Staff were observed to offer appropriate support to service users. Food stocks were observed to be satisfactory. Minutes of service user meetings evidence consultation on menu planning. Since the last inspection the menus have been developed so that they are available in a picture format, making them easier to understand for service users. A menu board in the dining area also displays pictures of the meals for that day. Discussion with the Manager indicates that she has recently been on a nutrition course, along with another member of staff. The Manager said this course had been really useful in helping to plan healthy menu’s. Records of food eaten were generally well completed but often entries for lunchtime meals were ‘packed lunch’. The Manager needs to ensure the detail of the packed lunch is recorded to evidence that these lunches are varied in content. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of service users are generally met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication are good and ensure service users receive the medication they need. EVIDENCE: As observed at the last inspection, the service users and staff appear to enjoy a good rapport. Support is given in a warm and friendly manner and people are treated with respect and consideration. Service users were dressed appropriately to their age, gender, the weather and the activities they were doing. Information on the type of support needed for personal care is included in the care plan. The service users are mixed gender. It was identified at the last inspection that all the staff at the home are female and therefore work needed to be done with service users to seek their views on the gender of the staff who support them. This has now been done and is included in the care plan. Progress has also been made on recruiting male staff, the home has one male casual staff and a new permanent male staff is due to commence soon. This will give the service users more choice on the gender of the staff they wish to support them. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 16 A sample inspection of service users’ health records indicates that service users are receiving routine access to general health services, such as well person’s checks, dentist, eye tests, flu vaccinations and chiropodist. Evidence of the regular weight monitoring of service users was observed. Service users are referred, where necessary to health professionals for advice. Service users have a health action plan. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. These were seen to be functional but quite basic in content. The systems for the safe storage, handling and administration of medication were well managed. The home utilises a monitored dose system for medication. Records that medication had been received, administered and where appropriate returned had been made. The home retains copies of prescriptions so that staff can check the correct medication has been received from the chemist. Audits are undertaken for non blistered medication. The training matrix shows that staff have received medication training. One new member of staff who has yet to do this training confirmed that they were not administering medication. As recommended at the last inspection medication competence assessments are being completed for staff on at least an annual basis. Warwick Road, 429 DS0000004512.V308086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure, which ensures service users views are listened to and acted upon. General practice within the Home offers protection from abuse, neglect and self-harm to the service users but systems for protecting service users belongings need to improve. EVIDENCE: The CSCI have not received any concerns or complaints about this home since the last inspection. The home’s complaint procedure was observed to be satisfactory. One service user spoken with said he would speak with the Manager if he was unhappy about anything, but there was nothing he was unhappy about. The comment cards received from relatives recorded that they were aware of the home’s complaint procedure. The training matrix for the home indicates that the majority of staff have received adult protection training. Staff who need this training have been booked to attend. Sample checking of the personal file of the most recently appointed member of staff revealed that CRB and POVA checks had been completed satisfactorily. At the last inspection it was identified that sometimes service users pay for staff who accompany them on activities, such as to the cinema. As required, this practice has now ceased. Sampled expenditure records did not show that the service users were paying for things that should be paid for by the Provider. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 18 Inventories of personal possessions were available for service users. Two of these were sampled, both were dated June 2005. A system of review of the inventories needs to be implemented so that robust tracking of personal possessions is done to include when new items are bought or old ones discarded. If audits are not done it is very difficult if something goes missing to identify if it has been thrown away. Warwick Road, 429 DS0000004512.V308086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is generally comfortable, homely and safe but some redecoration of communal areas in needed to ensure it is a nice place to live. EVIDENCE: Overall 429 Warwick Rd is an attractive home, providing accommodation on a large domestic, scale in a comfortable modern environment. The rear of the home has been extended to provide an attractive dining area overlooking the garden. This provides a comfortable area that benefits from good natural sunlight, in which service users can dine or relax. At the last inspection some communal rooms were starting to look a little ‘tired’ and the Manager said that a decorator had to visited to quote for redecoration. At this inspection it was noted that no redecoration of communal rooms had taken place. This must be scheduled as the dining area needed repainting due to staining on the walls, the hallway had several areas where the wallpaper was worn or torn and the lounge wallpaper looked tatty with a ripped area above a radiator. The seating in the lounge is also looking worn in Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 20 appearance, discussion with staff indicates that the home has had the same seating since opening about eight years ago. Some bedrooms have been decorated since the last inspection, service users have been involved in choosing the colours. One service user has had a mural painted on the walls by an artist, and the ceiling has been painted with pictures that reflect in a special light at night time. Bedrooms observed were generally personalised and were clean. Observation of bedrooms indicate that service users are supported by staff to have a bedroom that reflects their gender, age and culture. The home does not have a lot of storage space. Because of this, two dining chairs that had been awaiting repair for two months were kept in the entrance hall. The chairs had been reported for repair several times by staff but they were still awaiting the maintenance person to carry out the repairs. Warwick Road, 429 DS0000004512.V308086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff who know them well and are appropriately qualified. General recruitment policy and practice supports and protects service users. Arrangements for supporting and developing staff are good. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. It is a strength of this home that most staff have worked there for some time and so know the service users well. The pre-inspection questionnaire stated that all but one of the care staff have NVQ level 2 or above in Care. This exceeds the standard that at least 50 of staff have NVQ level 2 or above. Several staff have also completed the Learning Disability Award Framework (LDAF). Examination of the homes rota and discussion with the Manager indicates that in recent months the home has been short of staff but that vacancies are now filled. It was of concern that whilst the home had some staff vacancies the rota showed part of a shift where there were no staff on duty. The Manager said that service users had been at the day centre during this period. This is not good practice as service users may have needed to return home in an emergency, for example if they were taken ill and it may have caused the Day Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 22 Centre staff problems in trying to contact the home to get support for the individual. As stated earlier in this report it is good that one of the new staff due to commence work in the home is male, this will help the home move towards ensuring the gender of staff reflects the gender of service users accommodated. The Manager said that a volunteer had also been recently recruited but they had not yet started work in the home. The Manager said that the volunteer intended to work a few hours each week and would be assisting staff with service user activities. The recruitment records for one new member of staff were sampled. All the documents required were available including a Criminal Record Bureau check to show that the necessary checks had been completed to safeguard service users. The Manager was also able to evidence that a robust recruitment procedure had been followed regarding the volunteer. The Manager has completed a training matrix, this details the training staff have received and when refresher training is required. The matrix indicates that the majority of staff have received the training they need to meet the needs of service users. Discussion with a new member of staff and examination of records indicates that they are receiving a full induction to the home. Training completed by staff in the last twelve months includes service user empowerment, first aid, nutrition, medication, infection control, manual handling, and fire awareness The Manager sad that some staff had also attended a workshop about the CSCI and Care Standards. An examination of the home’s records confirmed that staff meetings are routinely taking place on a regular basis. The supervision matrix and discussion with staff shows that supervision is regular to ensure staff are well supported in their job role. Warwick Road, 429 DS0000004512.V308086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements generally ensure that service users benefit from a well run home. EVIDENCE: The Manager demonstrated good knowledge of the needs of the service users. She has many years experience in care and has successfully completed both an NVQ 4 and the Registered Care Managers Award. The Manager is making clear efforts to develop the service for the benefit of the people living in the house. All four comment cards received from health and social care professionals recorded that the home communicates clearly with them and works in partnership. Systems are generally in place to assure quality. There was evidence of statutory reports being completed by the representative of the organisation to evidence they are overseeing the running of the home and ensuring the health Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 24 and welfare of the service users. However there was no report for June and the visitors book did not evidence that a visit had been made to oversee the running of the home. Audits are carried out periodically to include health and safety issues. Discussion with the Manager at the last inspection indicates that annual quality audits are completed. This included questionnaires that were sent out to relatives. These were observed to have been completed in August 2005 but the Manager said she had not received a copy of the quality audit report. At this inspection the Manager said that the report from this had never been received and so staff were working on their own development plan for the home in consultation with the service users. Since the last inspection some good work has commenced to seek the views of service users. Staff are using questionnaires to seek their views, minutes of service user meetings show that this process has been explained to the service users. Detailed risk assessments were in place for staff, the premises, food and using equipment. These were regularly reviewed and updated where necessary to reflect any changes. Safety records were examined and showed that the fire alarm and emergency lighting systems have been serviced and checked regularly as required. Fire drills have been carried out regularly. Staff were up to date with fire training. The record of testing of water temperatures was seen and completed as required, they showed that water is maintained at a safe temperature for service users. Staff test the fridge and freezer temperatures regularly to make sure that food is being stored at the correct temperature. Warwick Road, 429 DS0000004512.V308086.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 3 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 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Warwick Road, 429 DS0000004512.V308086.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 YA17 Regulation 17(2) Sch 3 Requirement Records of food. The Manager needs to ensure the content of the packed lunch is recorded to evidence that these lunches are varied in content. Ensure the inventories of service users personal possessions are updated when items are purchased or discarded. Complete an audit of the standard of decoration of the environment and schedule redecoration of communal areas identified from audit. The Provider must ensure that repairs reported by staff are carried out without delay. The Manager must ensure that adequate numbers of staff are on duty at all times to meet needs of service users. The representative of the provider must undertake visits to the home on a monthly basis and produce a report of the visit. Produce report following the implementation of Quality Assurance and Monitoring System, ensuring that views of DS0000004512.V308086.R01.S.doc Timescale for action 30/10/06 2. YA23 12(1) 13(6) 23(2)(b,d) 30/10/06 3. YA24 30/10/06 4. 5. YA24 YA33 23(2)(c) 18(1)(a) 15/10/06 15/10/06 6. YA39 26 30/10/06 7. YA39 24(1-3) 30/11/06 Warwick Road, 429 Version 5.2 Page 27 service users are represented appropriately. Make available to interested parties, and forward a copy to CSCI. Outstanding previous requirement from 30/04/06. 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 YA6 Good Practice Recommendations Actions from service user review meetings: It is recommended that the system for identifying a timescale for actions and who is responsible for ensuring they are carried out is improved. Service user care plan formats: Each page had lots of small pictures and was a little confusing, it would be better if there were fewer pictures on each page so each picture could be bigger making it easier for service users to understand. Tidying up of service user files is needed to archive information that is no longer current. 2. YA6 3. YA6 Warwick Road, 429 DS0000004512.V308086.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: 0845 015 0120 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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