Inspection on 11/07/07 for 5 Shalnecote Grove

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

5 Shalnecote Grove 11/12/06

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 Ann Farrell Unannounced Inspection 11th July 2007 07:30 Shalnecote Grove, 5 DS0000017148.V337996.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.V337996.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.V337996.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.V337996.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 11th December 2006 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. Flat 10 is located on the first floor and is accessed via a separate public hallway. All of the flats are self-contained and have a kitchen, bathroom, lounge, bedroom and store cupboard. However, the privacy of the residents in two of the flats is compromised as one of the rooms, the toilet and the kitchen is used by staff in flat 3 and one of the rooms in flat 10 is used as the managers office, as there is no staff accommodation. These shortfalls in physical standard matters are detailed in the homes statement of purpose. There is adequate parking available to the front of the property and a garden to the rear for use by residents when the weather permits. The home provides a service to six service users who are deaf blind or have sensory impairment and additional disabilities with complex needs. Information about the services is not easily accessible to enable anyone visiting to make an informed decision about the home. Fees for accommodation and care range from £1609 to £3483.88 per month. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over one day commencing at 7.30am and no one from the home was aware of the inspectors visit prior to their arrival. This was the first statutory inspection for 2007/2008. The manager was present for the duration of the inspection. Information to inform the inspection included a tour of the building plus inspection of a sample of resident’s files and other documentation in relation to the management of the home. Case tracking was undertaken in respect of one resident, which included inspection of the residents room, any equipment used to meet their needs plus records in respect of care, medication, accidents, finances etc. to determine care from the time of admission. The inspector spoke with the manager, members of staff, the visiting district nurse and met with three residents. Many of the residents do not have verbal communication and their ability to communicate their views of the home to the inspector was limited, however some communication was possible as staff assisted in signing with service users. The inspector spent part of the inspection observing care practice. Information was also obtained prior to the inspection from the manager who had completed a form about the home and feedback was also sought through comment cards from health professionals and relatives. What the service does well: There is an enthusiastic staff team who have a good knowledge of the care needs of people in their care. Feedback from relatives stated, “excellent staff group who ensure a happy life for residents”, “Staff do a great job”. All residents live in their own flat, which were decorated and personalised to their own taste. This provides a pleasant environment to live, which enables residents to maintain their independence and privacy. Feedback from relatives stated, “ First Class accommodation”. Many residents have behaviours that challenge. Staff have all had training in this area of work and situations that arise are quickly diffused with diversionary tactics. There have been no recent major incidents in the home. A range of health care professionals provide a service to the home with input also from the community learning disabilities team, so meeting resident’s health care needs. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 6 Visiting was flexible enabling residents to maintain contact with friends and relatives at a time that suits them. Feedback indicated that relatives were informed of any important issues and kept up to date with changes. Residents clothing was clean and well pressed, so respecting their dignity. What has improved since the last inspection? What they could do better: The service user guide needs to be developed in order to provide prospective residents and their representatives with up to date information about the services and facilities to enable them to make an informed choice about moving into the home. This should also be produced in a format that is accessible to residents. Care plans and risk assessments must be reviewed and updated to provide clear, concise information required to meet resident’s needs and reduce any risks. There needs to be a more pro-active approach to care with monitoring of residents conditions, early detection and communication of any problems and referral to health professionals where appropriate to prevent complications and meet residents health needs. Once health professionals have visited robust systems need to be in place to ensure that the instructions are implemented and residents health care needs are met. A review of the communication systems should be undertaken and action taken to ensure any information or concerns about residents is made known to all staff to enable action to be taken where necessary. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 7 A review of the medication system needs to be undertaken to ensure it is fully auditable to demonstrate residents are receiving the medication prescribed to them by health professionals. Staff training is required in an number of areas including working with people who have a Learning Disability, deaf/blind, fire safety, infection control, moving and handling etc to ensure staff have the appropriate knowledge and skills to meet residents needs and records should be retained in the home. The arrangements for activities should be reviewed and developed further to provide a greater opportunity for community activities, so residents lead a meaningful and fulfilled life. Maintenance and repairs to the environment identified must be carried out in a timely manner, to ensure residents live in a pleasant, safe and well maintained environment. The lighting needs to be reviewed to ensure it meets the resident’s needs and reduce the risk of any accidents. 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.V337996.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.V337996.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): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information about the service and facilities needs development to enable prospective residents and their representatives to make an informed choice about moving into the home. There have been no new admissions to the home for the pat 7 years. EVIDENCE: There is a static resident group in the home with all residents having lived in the home for a number of years. There is information available about the services in the form of a statement of purpose, which was seen at the last inspection and found to be of a satisfactory standard. The information provided indicated that the service user guide had been updated. On inspection it was found that a two-page typed document had been produced, which was in each residents file and was specific to them with individual photographs and some brief comments about the home. This will need to be reviewed and a comprehensive service user guide drawn up that outlines the services and facilities to enable any new residents or their representatives that may wish to enter the home at a later date to make an Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 10 informed choice. It is recommended that it is produced in a suitable format that is more accessible to residents e.g. pictures, audio or video. The statement of purpose, service user guide and the latest report from the Commission should also be made more accessible to anyone visiting the home. Shalnecote Grove, 5 DS0000017148.V337996.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments need reviewing and updating to ensure all residents’ needs and risks are identified and met in a consistent and appropriate manner in line with resident’s preferences. EVIDENCE: All the residents in the home have complex needs as they are deaf and have a sensory impairment. Communication methods used with staff include body language, signing, the use of photographs, pictures and objects of reference. All residents have communication boards in their individual flats identifying staff and events in their lives. Interaction between staff and residents was observed to be good and residents were seen to be relaxed, smiling and using gestures to indicate they were happy when communicating. A member of staff undertook signing to enable the inspector to talk to one of the residents and the feedback indicated they were happy living in the home. The manager Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 12 stated they do not have any residents meetings due to the diverse abilities of residents and staff discuss any matters with residents individually. The home is in the process of changing the staff facilities and care plans are now stored in residents own flats. One residents care plan was inspected in depth and there was information about communication needs, independence and life skills. In addition, there were some individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. There was information about likes and dislikes in respect of activities plus food and drink. There was also a range of risk assessments in respect of areas such as going out, washing, etc. They stated how all risks to individuals are to be minimised without compromising their development and independence. Each risk assessment was cross-referenced to the element(s) of the care plan to which it related, and vice versa, so that the reader is directed from one to the other. This document provides staff with the information they require to meet resident’s needs. On inspection it was found that some areas of the care plan were detailed, but other areas lacked detail or had vague comments. There was repetition in some areas, some of the areas had not been reviewed regularly and some areas referred to risk assessments that were not in place. On inspection of some of the risk assessments there were no strategies in place to manage risks that had been identified. The document was difficult to follow as there were a number of files to refer to in order to find the relevant information, there was no evidence that residents had been involved in the process and the format was not suitable for residents to access and understand. Without up to date information it cannot be guaranteed that staff were aware of how resident’s needs should be met. It was stated that a practice development worker was responsible for ensuring all care plans were up dated. However, the practice development worker does not appear to be in the home on a regular basis and care plans/risk assessments had not been consistently reviewed and updated. This area must be reviewed and action taken to ensure all care plans are reviewed, updated and are easy to follow so that staff are fully aware of how residents needs should be met Daily records were recorded by staff for each shift indicating the activities or care provided during the day plus diet and fluids taken, so enabling staff to monitor residents progress and well being. The daily records did not give any information about how the resident enjoyed their day or the activities undertaken, to determine if it was suitable or if changes were required. In one case it was uncertain from the record if the activity had been undertaken or if it was the scheduled activity. The record of food was not detailed and it could not be confirmed that the resident was taking a nutritious diet. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 13 Core team meeting are undertaken by staff approximately once a month where a resident’s condition, progress etc is discussed. It was noted that staff had identified one resident was loosing weight and a referral should be made to the dietician. However, there was no evidence that a referral had made and staff were unable to confirm that any referral had been made. This is concerning as it demonstrates problems with communication within the home, which could ultimately affect the residents well being. The communication systems must be reviewed and action taken to address shortfalls and appropriate action taken to ensure resident’s needs are met. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual lifestyles are known by staff and acted upon in some cases. This area will need to be reviewed and developed further to ensure adequate resources are always available, so enabling residents to lead a meaningful and fulfilled lifestyle. EVIDENCE: Resident’s files had a list of activities they enjoyed enabling staff to arrange a variety of activities to meet their needs and preferences. There was an individual programme of activities for all residents. However, it was noted that a number of activities were around domestic aspects such as shopping, living skills, ironing etc, plus in house activities such as music. It appeared that some of the residents had few activities outside the home. Currently two residents work at the organisations garden room, where they are involved in producing garden furniture. On the day of inspection three Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 15 residents were going out to a college to enrol for some college courses. Other activities included, a walk, a massage, visits to the deaf club or a choice of the residents. The majority of the activities were undertaken during the day with few evening activities. The home has two vehicles to transport residents to activities, but it was stated by staff that some of the residents are unable to travel with others, so this can at times result in limited outings for them. The home also uses a number of agency and bank staff. On the afternoon of the inspection there were two agency staff plus one member of bank staff on duty and this may impact on the activities outside the home. There generally appeared to be limited opportunities for residents to undertake a variety of activities or to experience new activities in order to experience a fulfilled life. This area will need to be reviewed and action taken to develop it further in order to provide more opportunities to residents for stimulation and social interaction. A resident with high dependency needs required 1:1 staffing 24 hours per day had his own small staff group. His interests lie in a range of external physical activities rather than in door activities. He goes to the gym and Star City on a regular basis, but there was an extensive list of activities that they were interested in and could have been included in the plan of activities. Family contacts are promoted, so enabling residents to maintain contact with relatives and keep them updated with any events and changes. It was stated that staff send a newsletter to one resident’s family on a regular basis, so keeping them updated with their progress. The manager also speaks to family regularly, so keeping them updated. There were two residents who do not have any active family involvement and it was stated that staff were looking for advocates, who could provide the residents with support. Feedback from relatives indicated that the home usually helped with communication between them and the resident. SENSE has a family liaison officer who’s role it is to facilitate working with families. They have held a ‘family weekend’ at a local hotel, in the past and this provides an opportunity for relatives to keep up to date with SENSE plans, meet with staff and other relatives. Residents were involved in making choices about the meals they want. They are involved in the shopping and preparation of the meals with support by the staff, so maintaining their independence as much as possible. Two residents were going shopping on the day of inspection. Records of food intake were maintained and residents were weighed on a regular basis to monitor that they were taking a nutritious diet. As identified earlier in the report the record for one resident indicated they were not receiving a nutritious diet, they were loosing weight and it had been identified that a referral to health professionals was required. The record of food intake was found to be inadequate. On discussion with the manager he stated they were in the process of reviewing the records and showed a sample of a new form that was to be used. Some staff training will be required around the use of the form to ensure they are Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 16 completed effectively. Also systems will need to be put into place to ensure they are monitored on a regular basis, to ensure they are completed correctly and residents are receiving a nutritious diet. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support is provided by staff in an appropriate manner ensuring residents maintain their independence where possible. Systems are in place to monitor resident’s health care needs, with visits from health professionals. There needs to be a more proactive approach to care to ensure all residents health care needs are met in a timely manner. The medication system could not be audited and so it could not be confirmed that residents receive all the medication prescribed to them. EVIDENCE: All residents live in their own flats in a housing complex and are visited by staff throughout the day or night as required, so providing the level of care they require. The circumstances ensure privacy for people and a degree of independence in their lives. Information about the support residents required in order to maintain personal hygiene was included in their care plan. On discussion with staff it was stated that residents needed prompting or supervision and the records confirmed this. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 18 Care plans also included manual handling assessments and information on gender specific support. Residents were dressed appropriately for their age, culture, gender and weather. Records showed that residents had regular check ups with the dentist, chiropodist and optician. On inspection of one residents file it was noted that they had been loosing weight. They had been seen by a G.P. some months previously, who was to discuss the situation with a colleague. The resident continued to loose weight and in June 2007 it was identified at a core team meeting that a referral should be made to a dietician. There was no evidence of any referral and on discussion with the manager he stated he was not aware of the concern or any referral. The manager stated that such issues would be discussed at staff supervision and action taken. However, on inspection of the staff supervision notes there was no evidence of the issue being discussed at all. This is not acceptable as there should be a more proactive approach with early referral to health professionals and follow up when any concerns are identified. It is recommended that a multidisciplinary team meeting occur to discuss the care of the resident and the future course of action. Each resident has a health action plan; this is a document that outlines the care a resident with learning disabilities requires to stay healthy. It is recommended that this be developed further to include the information required should the resident be admitted to hospital for any period of time. All records are now in individual residents flats and it would be beneficial if some areas were made more accessible to residents to enable understanding by the residents. Individual accident books are now also held in each flat and they had been completed satisfactorily. On inspection it was noted that some incidents had been recorded, but had not been reported to the Commission as required under regulation 37. The manager will need to follow up this area and ensure all incidents and accidents resulting in injury are reported to the Commission as required. Medication is stored in each flat in locked cupboards and staff retain the keys to the cupboards. Within the locked cupboard is a further locked metal medication cabinet to house required medication. It was stated that residents are involved in the medication as far as possible. They go to the chemist to collect it and some sign the record indicating that they have taken the medication. On inspection of two residents medication it was not possible to audit it and so it could not be confirmed that residents received the medication prescribed. Copies of prescriptions were not available to check that the correct medication had been recorded and there were no balances at the beginning of each moth to enable auditing to take place. The manager will need to review the system and take appropriate action to ensure the system is fully auditable to demonstrate residents are receiving the correct medication. It was stated that staff had undertaken medication training. On inspection of training records it was noted that some of the training was medication Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 19 awareness and it was not clear as to the depth of the training to ensure staff who administer medication maintain a safe and robust system. Whilst undertaking the medication audit the member of staff was unable to indicate why a particular medication was prescribed for a resident. Where staff are administering medication they should know what the medication is used for and the common side effects. It is recommended that a separate sheet should be available at the front of each administration chart indicating the drugs, the use and common side effects, to ensure all staff are aware of the medication they are administering to residents. A nebuliser was in use for some medication, but there was no evidence that the filter in the machine had been changed, so ensuring that it was in good working order. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place for safeguarding residents. Information should be made more accessible to residents to enhance understanding. EVIDENCE: There is a written compliant procedure on display on entering the home. It was recommended that this be in a format that is more accessible to residents to enable understanding. Residents have either family or advocacy support as a means of identifying concerns or complaints. Feedback from relatives indicated that they were aware of the complaints procedure and any issues that were raised in the past had been dealt with appropriately. The information provided by the home indicted that they had not received any complaints in the last twelve months and the Commission had not received any complaints about the home. The information indicated that there had been one referral under the adult protection procedures that had been investigated and appropriate action taken. This record was not made available to the inspector and copies should be in the home at all times. Resident’s records included an inventory of their belongings, which was comprehensive, so providing a record off all the residents’ belongings. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 21 Two residents financial records were sampled and the money was held in individual wallets. Money cross-referenced with the amount on their financial record and receipts were kept for all transactions. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 22 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): 24,25,27,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Accommodation is provided in individual flats, which were well personalised according to residents taste and they promote their privacy and independence. Attention is required to minor repairs and lighting to enhance the facilities for residents. EVIDENCE: There are six separate flats in this complex, which is owned by Moseley and District Housing Association. Five of the flats are located on the ground floor off a corridor area. The sixth flat is on the first floor and is accessed by a separate entrance. Flats are all self-contained and have doorbells and flashing alerts, so enabling residents to maintain their independence and alert them in case of a visitor of fire. All doors have locks so enabling privacy to be maintained. However, privacy was compromised in two of the flats as one flat accommodates the manager’s office. The second flat is used by staff during the day and at night for sleeping in, as there are no staff facilities. Currently the staff are in the process of moving office equipment out of the residents Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 23 room to a small office area, which is off the corridor. However, the flat will still be used for sleeping in, toilet and kitchen facilities. The staff hand washing facilities in the toilet area were not adequate to meet infection control standards and this issue will need to be addressed. The issue of staff facilities will need to be reviewed constantly and action taken to enhance resident’s privacy where ever possible. On entering the corridor it was dark, uninviting with poor lighting. This should be addressed in order to provide a more homely atmosphere and meet resident’s needs and reduce the risk of any accidents. Four flats were seen and they were homely, decorated and personalised according to residents taste. They consisted of a lounge/dining area, kitchen, bedroom and bathroom. Five of the bathrooms had a toilet and bath and one had a shower facility, so meeting residents bathing needs. The flats were clean and adequately heated with good furnishings. Call bells were available in each flat to enable residents or staff to call for assistance when required. It was noted that the control panel was situated in the residents flat that was used by staff for sleep in duties. On discussion with the manager he stated they were not used and it was noted that they had not been serviced since 2003. This area will need to be addressed. Whilst touring the flats it was noted some minor repairs were required that included; cleaning of extractor fans, a cover to an extractor fan was missing, the melamine was coming away from kitchen cupboards, light shades were broken, bathroom flooring needed replacing and paintwork was damaged. The manager stated they were in the process of obtaining quotes for some new flooring and curtains. Also some flats are due for re-decoration in the near future, which will enhance the environment for residents. The issues in respect of minor repairs and maintenance have been brought up at previous inspections and the manager has written to the housing association, but no action has been taken to date. This must be pursued further as it is not acceptable that these issues are ongoing for so long. There is a small garden, which can be accessed by residents. A shed was available, which contained a range of garden equipment and paint etc, but it was not locked and opposed a risk to resident. This must be kept locked when not in use. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the level of staffing in the home were adequate to ensure resident’s basic needs were met. The staff team were able to communicate with residents, so needs could be identified and met. Further staff training and a review of skill mix is required to ensure staff have the skills and knowledge to care for residents, ensure their needs are met and it does not impact on community activities. EVIDENCE: On discussion with staff it was stated there were usually three members of staff on duty during the day and one sleep in member of staff over night. In addition, there is one resident who has 1:1 care throughout the 24-hour period. This person basically has his own staff group due to the very high dependency and safety needs. Staff on duty were observed to treat residents with respect and observe their privacy. Staff spoken with had a good knowledge of individual need. The information provided by the manager indicated that the use of agency staff had reduced and they were waiting for the checks to be undertaken for Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 25 two new staff. On inspection of duty rotas it was noted that it is an integrated system completed over a nine-week period, which tries to offer a balance of gender, culture and skills to meet residents needs. However, at times there was a bank member of staff and two agency staff and this was observed on the afternoon of the inspection. Although the home uses preferred agencies this does not consistently ensure the staff are fully aware of residents needs and have the appropriate training to meet residents needs. The duty rota should be reviewed to ensure there is always permanent member of staff on duty who is fully aware of residents needs and have the appropriate training. Some new care staff and a deputy manager had been appointed since the last inspection, so increasing the management presence in the home and providing more continuity. A small selection of recruitment files were inspected and it was found that an application from, health declaration, photograph, Criminal Record Bureau Check and two references were in place plus a contract of employment, so ensuring a robust system. When the inspector arrived at the home staff organised themselves and stated there was a co-ordinators file. However, they were unable to access the file as it was locked in the manager’s office. This system will need to be reviewed to ensure the information is available to staff as to the co-ordinator and any events/activities that are planned for the day. Induction training for new staff was organised centrally by SENSE and includes areas such as protection, first aid, equality, values, diversity, working with deaf/blind people, communication manual handling, medication, challenging behaviour etc. Staff also complete modules over the six-month period that have a question and answer section and signed copies of these were shown to the inspector. This ensures staff receive the training required to meet residents needs initially. Staff also undertake an induction into the home and receive a starter pack, but there was no record of this. It was recommended that the manager draw up a document that outlines the areas covered and it is signed by the new member of staff and the member of staff who is inducting them. The information provided in respect of staff training indicated that some staff had not undertaken training in core areas, so they did not have the appropriate knowledge and skills to meet residents needs. Ares such as manual handling, health and safety, basic food hygiene, infection control and fire safety. Although some staff had undertaken first aid training some time ago it required updating and there was not a first aider on each shift to ensure that in the event of a medical emergency appropriate treatment would be given. All staff had not undertaken two fire drills over the past year and on discussion with some staff they were not fully aware of the procedure. The manager must ensure all staff undertake at least two fire drills each year to ensure they are fully aware of the procedure in the event of a fire and residents are protected. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 26 There were also shortfalls in training in relation to the resident group such as working with deaf/blind people, communication etc. Also some training will be required in medical areas such as diabetes, asthma, nutrition etc. to ensure staff are able to manage and care for residents medical needs. Staff were observed to be competent in communication with residents using British Sign Language or other communication methods used by residents, as they do not have speech. The inspector was not able to communicate with residents directly, but staff showed good interpretive skills. The manager stated ten staff had competed NVQ 2 training in care, although the training matrix only identified five as having completed the training. On inspection of staff files evidence of training was not consistently available. The manager must ensure there is evidence of training that staff have completed to support the information provided and the training matrix to demonstrate the range of knowledge and skills staff posses. Staff supervision is undertaken regularly to discuss staff progress, strengths/weaknesses, any concerns, and training needs. As identified earlier there were some areas of concern that were not addressed. The manager will need to review the system and communication in the home to ensure action is taken in a timely manner to address any concerns. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements have been strengthened with the employment of the deputy manager, so enabling systems to be fully implemented. Satisfactory systems are in place to promote the health and safety of residents. EVIDENCE: The Registered Manager has the required experience to run the home and is presently completing the NVQ4/Registered Managers Award. Since the last inspection a deputy manager has also been employed, so providing a stronger management presence in the home, enabling auditing systems etc. to be implemented Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 28 In the past there have been staff focus groups and audits of various aspects of the home. The manager stated they do not have resident meetings and discuss aspects about the home with residents on an individual basis. Residents do not have any input into staff recruitment, staff meetings and there was no evidence of feedback from residents to influence the quality assurance process. Also there was no evidence of feedback from other stakeholders regarding the quality of service provided. The manager will need to develop the quality assurance system to include feedback from all stakeholders and draw up an annual development plan indicating outcomes for residents. Consideration should also be given as to how resident input could be used to influence the running of the home enabling them to have more control over their lives. The information provided by the manager in relation to servicing and maintenance of equipment indicted that it was all up to date. A sample of records were inspected to include fire system, emergency lighting, fire extinguishers, electrical appliances, call bell system etc. It was found that the call bell system had been serviced in 2003 and the extinguishers had last been checked in September 2005, also the check on the electrical wiring system was due to be undertaken. These areas will need to be completed to ensure all equipment in the home is safe for use. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 29 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 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X X 2 Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 30 YES 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. 1. Standard YA6 Regulation 15(1)(2) Requirement Care plans must be reviewed and updated to provide a clear current record of residents needs and the actions required to meet those needs, so that all staff are aware of what is required and residents needs are met in a consistent manner. Timescale of 28/2/07 not met. Risk assessments must be reviewed and completed for all resident activity where there is perceived risk and it must detail the action required by staff to minimise the risk. Timescale of 12/12/06 not met. There must be a more proactive approach to care with early identification and communication of concerns, referral to appropriate health professionals and follow up where necessary. Systems must be in place to ensure all accidents/incidents in the home are reported to the Commission as required under the regulations. The medication system must be fully auditable with copies of DS0000017148.V337996.R01.S.doc Timescale for action 30/09/07 2. YA9 13(4) 15/08/07 3 YA19 12(1) 13(1) 20/07/07 4 YA19 37 20/07/07 5 YA20 13(2) 20/08/07 Shalnecote Grove, 5 Version 5.2 Page 31 current prescriptions available, so that it can be confirmed that residents receive the correct medication. Written consent must be obtained for flu injections. All staff who administer medication must have completed appropriate medication training to ensure they are competent to administer medication safely. 23(2)(p)(d) The main corridor lighting should be reviewed and improved to meet resident’s needs especially as some of the residents have visual problems. 13(4) The shed in the garden must be kept locked at all times when not in use to reduce the risk of accidents to residents. 23(2) The minor repairs identified should be addressed with expediency in order to provide a homely, safe and hygienic environment for residents to live. 16(2)(j) All staff must undertake training 17(2) in respect of basic food hygiene and records must be retained in the home to ensure staff have the appropriate knowledge and practice to maintain adequate hygiene standards in the kitchen and when handling food. 13(5) 17(2) All staff must undertake updated training in respect of moving and handling residents, systems must be in place to ensure good practice at all times to ensure residents safety and records must be kept in the home. Timescale of 30/1/07 not met. All staff must undertake training DS0000017148.V337996.R01.S.doc 6 YA24 30/09/07 7 YA24 20/07/07 8 YA24 30/09/07 9 YA32 30/09/07 10 YA32 30/11/07 11 YA32 13(3) 30/12/07 Page 32 Shalnecote Grove, 5 Version 5.2 17(2) in respect of infection control and systems must be in place to reduce the risk of cross infection and. Records must be kept in the home 12 YA32 13 YA32 23(4)(d)(e) All staff must undertake 30/08/07 17(2) updated training in respect of fire prevention and fire drills at least twice a year and be able to demonstrate the action to take in the event of a fire to ensure residents safety in the event of a fire. Timescale of 30/1/07 not met. 13(4) Staff must undertake training in 30/11/07 17(2) respect of first aid and there must be one first aider on each shift to ensure residents receive appropriate treatment in the event of an accident. 234(4) The extinguishers must be checked on a regular basis to ensure they are working properly and are safe in the event of a fire. Evidence must be retained in the home to demonstrate this. The call bell system and electrical wiring systems should be checked on a regular basis to ensure they are safe for use. 30/07/07 14 YA42 15 YA42 13(4) 20/08/07 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 The service user guide should be reviewed and developed to provide prospective residents and their representatives with information about the services and facilities to enable them to make an informed choice about moving into the DS0000017148.V337996.R01.S.doc Version 5.2 Page 33 Shalnecote Grove, 5 home. The service user guide should be provided in alternative formats, so that they are more accessible to residents and easier to understand. The statement of purpose, service user guide and last inspection report should be made more accessible for anyone visiting the home. The manager should review the communication systems in the home to ensure all staff have the required information to ensure residents needs are met in a timely manner. The arrangements for activities should be reviewed to provide a wider range of activities with some community involvement where appropriate, to ensure residents are adequately stimulated and enjoy a fulfilled life. Arrangements should be made for involvement of advocates where residents do not have any active family support to ensure residents are supported and their best interests are considered. A review of the system for monitoring and recording residents food and fluid intake should be reviewed to ensure staff are alerted to any concerns at an early stage to enable appropriate action to be taken. A system should be implemented where the filter on the nebuliser is changed on a regular basis in line with the manufactures instructions to ensure it works effectively. The health care plan should be developed further to include information required by staff should residents be admitted to hospital. Consideration should be given to making residents records more accessible to them to enable better understanding. It is recommended that a list of current medication, the use and common side effects be made available in residents medication file. The complaints procedure should be made more accessible to residents to enable understanding. The area should be painted to provide a more inviting environment. A review of staff accommodation should be undertaken and action taken to ensure residents privacy is enhanced. Advice should be sought about the most appropriate method for staff hand washing facilities in the bathroom used by staff to reduce the risk of any infection. A review of the staff rota should be undertaken, so an appropriate skill mix of staff is on duty at all times to ensure resident’s needs are known and met. When recruiting new staff it is recommended that DS0000017148.V337996.R01.S.doc Version 5.2 Page 34 2 3 4 YA1 YA6 YA12 YA13 5 YA15 6 YA17 7 8 9 10 11 12 13 14 15 16 YA19 YA19 YA19 YA20 YA22 YA24 YA28 YA30 YA32 YA34 Shalnecote Grove, 5 17 18 19 20 21 YA35 YA35 YA35 YA36 YA39 residents be involved in the process. A record of staff’s induction to the home and resident group should be retained in individual staff files. Training should be provided in areas of physical conditions such as diabetes, asthma, nutrition etc. to ensure staff have the appropriate knowledge to meet residents needs. Evidence of the training staff have completed should be held in the home to demonstrate the training completed and the range of abilities. The system of staff supervision should be reviewed to ensure all relevant areas are discussed and acted upon. The quality assurance process should be developed further to include feedback from residents, staff and other stakeholders and an annual development plan drawn up demonstrating developments for residents and in the service. Shalnecote Grove, 5 DS0000017148.V337996.R01.S.doc Version 5.2 Page 35 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.V337996.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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