Inspection on 11/12/06 for 5 Shalnecote Grove

This inspection was carried out on 11th December 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Shalnecote Grove 11/07/07

5 Shalnecote Grove 26/10/05

5 Shalnecote Grove 25/05/05

5 Shalnecote Grove 02/12/04

5 Shalnecote Grove 24/06/04

5 Shalnecote Grove 28/01/04

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 Shalnecote Grove, 5 Kings Heath Birmingham West Midlands B14 6NG Lead Inspector Peter Dawson Unannounced Inspection 11th December 2006 11.30:0 Shalnecote Grove, 5 DS0000017148.V323571.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 Shalnecote Grove, 5 DS0000017148.V323571.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. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalnecote Grove, 5 Address Kings Heath Birmingham West Midlands B14 6NG 0121 441 1640 0121 443 5723 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Darren Hanna Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be aged 18-65 years. The service may provide personal care only for six persons (6) with a learning disability and sensory impairment 26th October 2005 Date of last inspection Brief Description of the Service: Shalnecote Grove is a complex of flats owned by Moseley and District Housing Association. SENSE are the care providers and the registered owners. This inspection report relates to Shalnecote Grove, which consists of six flats registered as one service. Flat 1,2,3,4,5,are all on ground floor level and are located within a communal hallway with a coded door pad. Flat 10 is located on the first floor and is accessed via a public hallway. All of the flats are selfcontained and have a kitchen, bathroom, lounge, bedroom and store cupboard. The flats are accessed off a small-enclosed hallway. In flat 3 there is a sleep in room for staff. The one service user and the member of staff who is undertaking the sleep in duty currently share the bathroom facilities. In flat 10 there is waking night staff, staff share the one service users bathroom. These shortfalls in physical standard matters are detailed in the homes statement of purpose, there are guidelines in place in respect of this and these arrangements continue to be reviewed. The home provides a service to six service users who are deaf blind or have sensory impairment and additional disabilities and complex needs. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were 6 people in residence at the time of this inspection. Five have been resident for 12 years at Shalnecote Grove, one has been resident for the past 7 years. The Registered Manager was approved by CSCI following the last inspection. This unannounced inspection was carried out by one inspector on one day from 11.30 am – 5.30pm. A pre-inspection questionnaire was sent by the Manager to CSCI prior to the inspection and provides a basis of information for this report. The Manager and 5 staff on duty throughout the day were seen and spoken. Three residents were seen in their flats, one was at home but did not like receiving unknown visitors. Two were in the community involving activities. Three flats were inspected and the 2 staff room areas also used during the inspection. One resident provided written feedback to CSCI prior to the inspection supported by a member of staff. He indicated satisfaction with the care and routines of the home and understood how to make a complaint. There was no written feedback from relatives. Staff on duty impressed as having a detailed knowledge of residents needs and observed to be sensitive, helpful, respectful and supportive to residents during the inspecton. None of the residents have speech and some limited communication was established with them only through members of staff. Residents were observed to be comfortable in their individual flats and moved freely around. There were tactile trails to promoted independence. There are no communal areas each flat being self-contained for living purposes. One resident requires 24 hour support 1:1 and a staff group in place to facilitate that. The inspector was impressed with the member of staff and the understanding and communication skills with the particular person who has high dependency and safety needs. A very flexible but supportive approach was given in supporting a quality of life within those restrictions that maximised expression and choice for the person. The standards of care provided for this person were particularly high. The current scale of charges for Shalnecote Grove are reported to be £1,571 £3,542 per week. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A new Registered Manager has been approved by CSCI Risk assessment formats have been changed to quantify the level of risk. Vacant posts have been filled with less use of agency staff. More drivers are available having completed road safety tests. Money is available for taxis, trains and bus transport. Activities are no longer cancelled due to shortfalls of staff and transport. Outcomes of all complaints are now recorded. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 7 Protocols for PRN medication are now dated and contain clear instructions for circumstances of its use. 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. Shalnecote Grove, 5 DS0000017148.V323571.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 Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good statement of purpose. The Service Users Guide requires updating. There have been no new admissions to the home for the pat 7 years. EVIDENCE: There is a static resident group. Five have lived at Shalnecote Grove since it opened 12 years ago the other person has been resident for 7 years. There have therefore been no new admissions to the home for a considerable time. There is a statement of purpose which has recently been updated. This includes all required detailed information concerning the Sense organisation and particularly relating to the services provided at Shalnecote Grove. The Service Users Guide for each resident is in the process of being updated. Shalnecote Grove, 5 DS0000017148.V323571.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need updating/revision and risk assessments must be completed for all resident activity where there are perceived risks. Confidential information was secure and some good and detailed information provided. EVIDENCE: A sample of care plans are kept centrally in the ground floor office/sleep-in room and a sample of plans were seen. All are well established and contain considerable information. Changing needs require plans to be changed or updated and this takes place in the form of additional written comments. The plans need to be updated and provide more concise current information required to deliver care. There is a new Sense format for care plans and this was seen completed in relation to one resident, Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 11 work progresses for the remaining plans. The Practice Development Worker has some responsibility in this area. There is a new PDW who works part time and there is a backlog of required updating of information which she is addressing. Previous work in this area has been limited with sometimes poorly constituted plans in place. Work is in progress to update all information. Daily notes were seen relating to 2 residents and provided detailed daily information allowing some evaluation of the activities and progress of residents. Some activity sheets had again been manually updated with some information cancelled/changed. The positive side to this was that new and more innovative activities were being trialled with residents and changes needed to reflect this. The Manager hopes that the care planning information will be concluded by the end of January/February 2007. There is required input from the PDW. A requirement to define the level of risk in risk assessments was a requirement of the last report. There has been a working party established by Sense to deal with this issues and a new planning format put into place to indentify and record the risk level. In a challenging behaviour monitoring form it was reported that a resident had put the oven and all electric rings of the cooker on in his flat. This had not been subsequently risk assessed. The Manager will ensure a risk assessment is put into place for this. There are excellent risk assessments in place relating to the evacuation of residents from the home in the event of fire. There was a record of “disclaimer” – instances in relation to each resident where there may be some restriction upon rights. The information was accurate, concise and adequately detailed. In relation to a resident with no family contacts the home continues to provide ongoing photographs and information to the family. The possibility of the use of an independent advocate is being considered. Another resident with complex and high dependency needs does have the services of an Advocate. Regular visits by family continue and regular contact with the family by staff also continue. There were many instances observed where residents participated in activities of daily living and communication methods used with staff including body language, signing, use of photographs, pictures and objects of reference. All residents have communication boards in their individual flats identifying staff and events in their lives. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 12 Confidentiality is preserved with all personal records secured in the office areas of the home. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual lifestyles and aspirations are known and acted upon. Individual community activities with staff support are available to all. There is evidence of choice in daily living. EVIDENCE: There is an individual programme of activities for all residents. Very few activities are joint ones and they consist of 2 residents going to college together or for a meal etc. All activity programmes are tailored to individual needs and provide opportunities for personal development and involvement in community activities where possible. The Sense centres in Birmingham provide facilities for some residents, including music therapy, massage etc and provide a very positive experience. Where possible alternative facilities are used and it was good to see some innovative ideas. A resident with high dependency needs Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 14 requiring 1:1 staffing 24 hours per day has his own small staff group. His interests lie in external physical activities rather than former indoor craft-type activity. He goes rock climbing, ice skating and loves to be outdoors. Rather than simply going on walks he now goes to the gym which he thoroughly enjoys and is occupied positively. The support worker spoken to during this inspection who was allocated to provide the 1:1 support to this person for the day had established over a long period a positive means of communication and an exceptional understanding of his needs, dealing appropriately and professionally with his sometimes challenging behaviours which have social implications when in the community. He has made a very positive integration into the community increasing his quality of life. There were other examples of residents making progress in areas of domestic activity and social integration. These as a direct result of good assessment of need, risk assessments and positive action to trial new activity. Family contacts are promoted. With the exception of one all have family visits. Several go home and stay overnight, others have regular family visits. Staff will transport people to their families if required by train or car transport. One resident without family visitors has 2 ex-members of staff who support her and take her out for meals – acting in an advocacy-like role also. At the time of the last inspection activities had been limited or cancelled due to staff shortages, lack of vehicles/drivers and agency staff with individual and local knowledge. These issues have all been addressed. New staff have been appointed and there is now a consistent staff group for all residents, there is minimal use of agency staff. The home has 2 vehicles for constant use a car and 7/8 seater person carrierl. There are now 9 drivers who have completed the required road safety test. Additionally a weekly “float” has been established for the home to use for taxis or train travel and ‘bus passes obtained where appropriate. Transport is now constantly available to all residents upon demand. Food provision appears good. Residents are involved in shopping and preparation of meals in relation to their skill levels. All made individual choices about daily food. One resident was seen helping to prepare fish-finger sandwiches which was his choice for lunch. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is provided in appropriate ways. Health care records are detailed, relevant and meet required standards and here is a safe system of medication in the home. EVIDENCE: Residents do no have physical disabilities requiring interventions for personal care. Most required only staff oversight for personal hygiene needs. All residents live in their own flats in this housing complex and visited by staff throughout the day or night as required to provide the level of care they require. The circumstances ensure privacy for people and a degree of independence in their lives. The organisation supports the preferences for choices of gender support from staff. Daily activity programmes take account of individual preferences for daily living and support in accessing activities both inside and outside the home of their choice. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 16 Flats are all self-contained. Have doorbells/flashing alerts and secure when residents are alone. The flat on the first floor accommodates a person who has 1:1 care 24 hours per day with a waking member of night staff based there. The other 5 flats are on the ground floor and in a secure, self-contained corridor with an external door accessed only by residents or staff, visitors having to ring the relevant call bell. Staff are constantly in this area and one sleeps-in and on call in this area. It was reported that most residents have behaviours that challenge the service. This was discussed in detail with staff and behaviour monitoring forms completed in relation to each incident sampled. The records indicated a good standard of recording and all interventions deployed to diffuse situations using diversionary tactics. No injuries to residents or staff were reported in any of the recordings. All staff have received (NCI) training in the management of violence and aggression. There have been recent updates. The Manager provides training to Sense staff in other homes relating to this area of work. Physical restraint techniques are not required or used in this home. All residents have individual health care action plans, required in “Valuing People”. This information contains a chronology of interventions by health care professionals with past and future appointments recorded with dates and outcomes. These records were recently completed, were current and relevant. Residents are supported by health care professionals including specialist services from the community learning disability team. Medication is stored in each flat in locked cupboards (staff have keys) which contain a small further locked metal medication cabinet to house required medication and records. There are no self-medication possibilities at this time, although 3 people do “sign” MAR sheets to involve them in and promote some independence in this area. There is little use of anti-psychotic medication – used in relation to one person and is reviewed regularly by the Consultant Psychiatrist. All staff administer medication and have completed distance learning course in medication administration at Solihull College. Additionally all are assessed by Sense staff for competency over 6 months. A requirement of the last report to date and record reasons in protocols for PRN medication has been satisfactorily addressed. Shalnecote Grove, 5 DS0000017148.V323571.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The complaints procedure has been tested and found to be satisfactory in protecting residents from abuse. The outcome of current Vulnerable Adults investigation as a result of a complaint should be notified to CSCI when completed. EVIDENCE: There is a complaints procedure available for visitors in the reception hallway of the home. Additionally residents have a pictorial copy of the complaints procedures, efforts are made by staff to re-enforce and explain those procedures. All residents have either family or advocacy support as a means of identifying concerns or complaints. A complaint was made in July concerning the actions of a member of staff. This is was referred for investigation under the Vulnerable Adults Procedures and is still under investigation. Sense staff are involved in those investigations which have staffing implications and must notify CSCI of the outcomes and actions when completed. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 18 A requirement of the last report to provide details and outcomes of complaints has been actioned. The complaints book seen and either details entered in the complaints book or reports completed where further investigations are needed. Shalnecote Grove, 5 DS0000017148.V323571.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Accommodation in individual flats is good and promotes privacy and independence. Attention is required to minor repairs by the Housing Association. EVIDENCE: There are 6 separate flats in this housing complex. Five are located on the ground floor off a separate corridor area from the rest of the building. The main door has a keypad lock, there is privacy and security for residents. A room is used in 1 flat as a staff sleeping-in room. Flats on the ground floor have patio doors lading to a small patio area and garden beyond. There are also security issues which are known and monitored. There is sixth flat on the first floor which also provides an access to the office area with bathroom facility. This provides some independence and further exit route in the event of fire. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 20 Three flats were seen and were observed to be bright, homely and have good facilities including a lounge/dining area, kitchen, bedrooms and bathroom/toilet. They were all clean and adequately heated with good furnishings and personalisation. Two microwaves missing in kitchen areas are presently being repaired. The building is owned by the Moseley & District Housing Association and Sense are the registered providers. Some maintenance and replacement matters relating to the flats need to be resolved swiftly by the Housing Association. These relate mainly to minor repairs and include: Replacement/resealing of bathroom flooring. Knobs on bathroom and bedroom cabinets required replacement. Three light-shades in bedrooms, kitchen and hallway require replacement. Cover to fan in kitchen area needs replacing. Some redecoration of bedrooms required to synchronise with residents on leave. The Manager reports requests to the Housing Association are not actioned although letters have been sent. These matters must be resolved by the Housing Association and perhaps central Sense staff can support the Manager in resolving these relatively minor repairs which have been identified in Regulation 26 reports to CSCI and have been outstanding for some time. Shalnecote Grove, 5 DS0000017148.V323571.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good staff commitment and skill levels in communication with residents. The use of agency staff has been significantly reduced. Some areas of staff training require action. EVIDENCE: A requirement to reduce the number of agency staff employed was made in the last report. This has been addressed – new staff have been recruited, existing staff provide additional cover and staff within the Sense organisation who have knowledge of residents in this home provide additional cover. The situation at this time is satisfactory. Two regular agency staff are available, who known the resident, to relieve staff involved in 1:1 care for a resident throughout the 24 hour period. This person basically has his own staff group which is a necessary requirement in view of his very high dependency and safety needs. There is no Deputy Manager at this time. Two vacancies are presently advertised. Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 22 A sample of staff records were seen and all appropriate checks, references and documents were in place to ensure protection of staff. A recently appointed member of staff had shadowed early and late shift members and was undergoing an induction process and closely monitored. Four members of staff were seen during the inspection. There was a shift change at 2 pm and it was helpful for the inspector to be involved in the handover process. Each resident was reviewed to provide details of care over the previous 8 hours. Particular needs identified and agreed actions recorded. The 5 staff on duty were observed to have a detailed knowledge of the needs of residents an showed a high level of competency and understanding in supporting residents in the their activities. They promoted choice and independence in a very positive way. All talked with interest, sensitivity and professionalism about meeting the needs of residents. Staff commitment to resident need appears high. Staff were observed to be competent in British Sign Language and showed skills in other areas of communication with residents. None of the residents have speech. The inspector was not able to communicate with them directly but staff showed good interpretive skills. In the area of staff training it was surprising that only 4 staff have completed a course on Working with Deaf/blind people. Five staff have not had fire safety training and updates are required for 5 people in Moving & Handling. There are some shortfalls in other areas of staff training too. Application has been made for some of these courses (and others)- confirmation is awaited from Sense. All staff have, or are involved in NVQ training. Shalnecote Grove, 5 DS0000017148.V323571.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new Manager has made a positive impact upon the service. Staff commitment is high and there are no safe working practices requiring attention evident in the home at this time. The result of a vulnerable adults investigation must be reported to CSCI. EVIDENCE: The Registered Manager has the required experience to run the home and is presently completing the NVQ4/Registered Managers Award. The RMA has been confirmed and he is awaiting final assessment for the NVQ4. He was appointed Acting Manager from another Sense home but approved as the Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 24 Registered Manager in November 2005 by CSCI. This is the first inspection since that approval. The Manager promotes an open and inclusive atmosphere in the home having direct care contact with residents and working closely with staff. There are presently 16 staff employed, five were seen and spoken to during this inspection and all spoke very positively about their work at Shalnecote Grove showing understanding of resident need and their commitment to the philosophies of the home. Staff and Manager were involved in the hand-over at the 2pm shift change. There was positive discussion and clear opportunities for staff to express their views. They said that they were satisfied with the training provided by the Sense organisation. All staff were helpful and cooperative during the inspection process. Fire records were seen and all checks and servicing of equipment were checked and had been carried out as required. It was pleasing to see that an assessment had been made of residents abilities and needs in the event of fire and that this had been posted in the hallway being the main fire exit from the building. Five staff have not had fire safety training and this is in process. COSHH items were all locked in a separate cupboard away from the residents flats. Items brought and returned to the store by staff as they were required in the flats. Some updating training in moving & handling is required for staff. A requirement is made in relation to this. The home needs also to provide training in other areas as discussed and notified. The outcome of a recently completed investigation carried out by Sense under the vulnerable adults procedures, has not been notified to CSCI. There may be staffing implications arising from this which must be notified immediately under Regulation 37. Shalnecote Grove, 5 DS0000017148.V323571.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 x 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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 x x x 2 x Shalnecote Grove, 5 DS0000017148.V323571.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 28/02/07 1 YA6 15(1)(2) 2 YA9 3 YA32 4 YA24 5 YA42 Care plans must be updated to provide a clear current record of need and actions required to meet those needs. 13(4) Risk assessments must be completed for all resident activity where there is perceived risk. 18(1)(c ) Staff training required in Working with people with learning disabilities, Moving & Handling and Fire Safety. 23(2)(c ) Maintenance & repairs identified in Reg. 26 reports must be actioned by the Housing Association. 37(1)(e)(g) Outcomes of current vulnerable adults investigation must be notified to CSCI 12/12/06 31/01/07 31/01/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000017148.V323571.R01.S.doc Version 5.2 Page 27 Shalnecote Grove, 5 Standard Shalnecote Grove, 5 DS0000017148.V323571.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 Shalnecote Grove, 5 DS0000017148.V323571.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. Re-publishing this information is in breach of the terms of use of that website. 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