Inspection on 26/10/05 for 5 Shalnecote Grove

This inspection was carried out on 26th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 11/12/06

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 Kerry Coulter Unannounced Inspection 26th October 2005 13:30 Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 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.V262310.R01.S.doc Version 5.0 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.V262310.R01.S.doc Version 5.0 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) Sense West Vacant Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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 Changes to separate the alarm system will be completed within 6 months of registration 25th May 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 registered care providers. 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 self-contained and have a 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. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one inspector. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from May 2005. At this inspection time was spent observing care practices, interactions and support from staff. Some of the service users do not have verbal communication and their ability to communicate to the inspector their views of the home was limited. A tour of two of the flats was made. Service user care plans, risk assessments and a number of Health and Safety records were inspected. The inspector had the opportunity to talk with several members of staff, the Manager was on annual leave on the day of the inspection. During this visit the inspector did not have opportunity to speak with relatives and other professionals. What the service does well: What has improved since the last inspection? All but one of the requirements from the last inspection have been met. Some internal redecoration and replacement of kitchen worktops has taken place making the environment a more pleasant place to live. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): N/A EVIDENCE: None of these standards were assessed. No new service users have been admitted to the home and so the assessment process was not evaluated. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. Strategies for managing risks were generally clearly identified with only minor improvement required to ensure risk is effectively managed. EVIDENCE: Two care plans were sampled. Both were observed to have been recently reviewed. They included detailed personal profiles, personal goals and aspiration, specific information on service users communication needs and independence and life skills. In addition, some service users have individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. Minutes of these core meetings were available in the file sampled. Service users records include individual risk assessments. They state how all risks to individuals are to be minimised without compromising their development and independence. Each risk assessment is directly crossreferenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 10 These are regularly reviewed and updated where necessary. As required from the last inspection the risk of one service user evacuating the home when the fire alarms sound/flash has now been completed. Work still needs to be undertaken to ensure each risk assessment includes the level of risk and likelihood of occurrence, i.e. low, medium or high. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Adequate resources such as satisfactory staffing and transport are not always available and this sometimes impacts on the ability of the home to offer scheduled activities. EVIDENCE: The two service user files sampled contained an activity timetable and support plans for identified activities. Service users have a planned timetable for attendance at activities outside of the home that includes ice-skating, rock climbing, gardening, massage and the local Deaf club. The activities participated in for one service user were tracked. Over a twenty one day period eleven scheduled activities had not taken place. Records indicate that this was due to a variety of reasons to include low staffing, no vehicle and on one occasion staff did not know how to get to the venue as the directions were not available. In all instances alternative in-house activities had been offered or a short walk. The Manager must ensure that resources such as staffing and transport are available to ensure planned activities are not frequently cancelled. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Service user personal and physical health care needs are met. The systems for the administration of medication are generally good but improvement to systems for ‘as required’ medication is needed, to ensure service users get the medication they need. EVIDENCE: Information on the support required by individuals for their personal care was observed to be recorded in their care plan. Sampled care plans included manual handling assessments and information on gender specific support. Records showed that service users have regular check ups with the dentist and optician. Other health professionals are involved in their care where appropriate. Where one service user had recently been unwell the staff had taken appropriate action by taking him to hospital. Each service user has a health action plan, this is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. Sampled accident records had been satisfactory completed, this was an area that was identified at the last inspection as requiring improvement. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 13 The medication systems were sampled in two of the flats. Requirements from the last inspection have been met. Topical creams are now dated on opening, copies of prescriptions are retained and the records of medication received were satisfactory. Protocols are available for the administration of ‘as required’ medication. However those sampled were undated and lacked detail. They need to be dated to evidence they are kept under regular review and are current. Additional detail needs to be added to guide staff as to when to administer the medication. For example, if paracetamol is prescribed for pain the protocol needs to guide staff to recognise how the service user communicates they are in pain. If medication for constipation is prescribed staff need clear directions on how many days without the service user going to the toilet before it is administered. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Records in the home do not show that appropriate action has been taken in response to complaints received. EVIDENCE: The home’s complaints policy has previously been assessed as satisfactory. The CSCI has investigated no complaints from service users or any other source in respect of Shalnecote Grove flats in the last twelve months. The Manager notified the CSCI in September that the home had received a complaint from local residents regarding noise levels at the home (and also the SENSE home next door). The complaint log was examined in order to determine what had action had been taken to respond to the complaint. The log did record the complaint and that senior SENSE managers had been made aware. However it did not detail if the complainants had been responded to and if the complaint had been upheld/ not upheld. It was also observed that the outcome of a complaint received in September 2004 had also not been recorded. The action taken to respond to and investigate complaints needs to be available in the home to show that appropriate action is taken. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The two flats sampled at Shalnecote Grove were observed to reflect the individual tastes of each of the service users. The flats were observed to be clean. Each flat has a kitchen, lounge, bedroom, bathroom and lockable storage space. Five of the flats are accessed from a communal hallway with a coded doorway, and each has its own front door. Flat 10 is on the first floor level, and is accessed via a public hallway. Two of the flats require the service users and staff to share facilities. This shortfall is raised in the homes statement of purpose, and requires on going reviewing ensuring that there is minimum impact on service users. As required at the last inspection new worktops have been provided in the kitchens of two flats. Discussions with staff indicate that previous problems with the door entry system sticking have now been resolved. Some redecoration has also taken place in some flats where paint was worn. An examination of the maintenance book indicated that required repairs are reported and actioned. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33 The staff team generally have a good understanding of service user needs. The ratios of agency or inexperienced staff on duty sometimes impacts on community activities. EVIDENCE: The staff on duty were observed to support service users competently with patience and respect. Service users were supported by staff to undertake independent living skills at their own pace. Staff spoken with had a good knowledge of individual need. The staff handover between shifts was observed to conducted in a private place, information on the well being of all service users was passed on to the afternoon staff in a professional manner by the morning staff. Staff on duty were observed to have the required skills to support service users. Staff were observed to be competent in British Sign Language, this included an agency member of staff. As stated earlier in this report, some service user activities have not taken place due to ‘low staff’. Discussions with staff and rotas sampled indicate that minimum numbers of staff are maintained. However sometimes activities do not occur due to numbers of agency or inexperienced staff on duty. Discussion with staff indicates that two new staff are due to commence work in the home, hopefully once inducted the use of agency staff will reduce. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Satisfactory systems are in place to promote the health and safety of service users. EVIDENCE: Fire records indicated that an engineer has serviced the fire extinguishers, fire alarms and emergency lighting. Staff test the smoke detectors weekly and the emergency lighting monthly to make sure they are working. Regular fire drills take place to make sure that all service users and staff are aware of the procedure to follow if there was a fire in the home. The fire risk assessment showed what action has been taken to ensure the risks of there being a fire are minimised. A Corgi registered engineer has tested the gas equipment and stated that it was in a satisfactory condition. Staff test the fridge and freezer temperatures regularly to make sure that food is being stored at the correct temperature. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 18 Staff test water temperatures weekly. Records of these showed that these are safe. Risk assessments are in place for manual handling, infection control, electricity, gas, COSHH products, kitchen, lone working, food and hot water. These showed how the risks to service users are to be minimised. A valid certificate of employers liability insurance is available. Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Shalnecote Grove, 5 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000017148.V262310.R01.S.doc Version 5.0 Page 20 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 YA9 Regulation 13(4) Requirement Timescale for action 30/12/05 2 YA12 16(2)(mn) 3 YA20 13(2) 4 YA22 22 Attention is needed to detailing the level of risk within service user risk assessments. Outstanding from 30/7/05. The Manager must ensure that 30/11/05 resources such as staffing and transport are available to ensure planned activities are not frequently cancelled. ‘As required’ medication 26/11/05 protocols must be dated and include a level of detail to enable staff to be clear as to when it should be administered. The action taken to respond to, 30/11/05 and investigate complaints needs to be available in the home to show that appropriate action is taken. Outcome must also be recorded to indicate if upheld, not upheld. Action must be taken to reduce the use of agency staff. 30/12/05 5 YA33 18(1)(a) Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 21 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 Standard Good Practice Recommendations Shalnecote Grove, 5 DS0000017148.V262310.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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