Inspection on 22/11/05 for 54 Brookvale Road

This inspection was carried out on 22nd November 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

54 Brookvale Road 31/08/07

54 Brookvale Road 04/07/06

54 Brookvale Road 15/06/05

54 Brookvale Road 24/11/04

54 Brookvale Road 16/07/04

54 Brookvale Road 20/02/04

54 Brookvale Road 13/12/02

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 54 Brookvale Road Olton Solihull West Midlands B92 7HZ Lead Inspector Joe O’Connor Announced Inspection 22nd November 2005 09:40 54 Brookvale Road DS0000043666.V260228.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 54 Brookvale Road DS0000043666.V260228.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. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 54 Brookvale Road Address Olton Solihull West Midlands B92 7HZ 0121 708 1553 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) Robinia Care West Midlands Limited Miss Christine Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Should the standard of care within the home deteriorate due to the manager being responsible for two other homes, then an individual manager will be required. That Christine Beverley Higgins completes a recognised accredited training programme in physical intervention by 30th September 2005. 15th June 2005 2. Date of last inspection Brief Description of the Service: The service provided at Brookvale Road consists of a domestic three bedroomed house situated in a residential area of Olton in Solihull. The service is registered to provide accommodation and support three adults with learning disabilities. The current service users are three men. 54 Brookvale Road is in a road of similar properties and is within walking distance of local facilities. Solihull town centre is accessible by bus or train, as is Birmingham City Centre. Each service user has single bedroom accommodation. The rest of the house, consisting of a lounge, dining room, kitchen, bathroom, and shower room is shared on a communal basis. There is also an office that is also used as a staff sleep in room. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over a day. Two service users were present and one was able to convey his views about life in the home. A tour of the premises was undertaken. Service users’ care plans and risk assessments were inspected. A number of health and safety records were also sampled. The Inspector also spoke to two members of staff and the Registered Manager. Observations of care practices were also undertaken. This is the second inspection of the service for the current inspection year. For a full overview of the management of this service the report should be read in conjunction with the previous unannounced inspection report of 15 June 2005. What the service does well: Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not distinguishable. Service users receive friendly and professional support from staff that have an understanding of their needs. One service user was very proud to show his bedroom and of the large model he was building out of Lego building bricks. He also participates in a course in upholstery at an adult learning centre. The service user stated that since the last inspection his accommodation had become more cosy and homely. Another service user goes out horse riding once a week. It was good to see that both service users were able to go on holiday individually and not have to go in a group and go to a destination of their choice. Each week service users are consulted on their preferred activities and the menu for the coming week. The manager has ensured the minutes for these meetings are written in a typed format. The manager ensures any complaints made by service users are listened to and acted on. Two service users’ bedrooms were viewed and these were found to be decorated and personalised to their individual tastes. One service user commented how much he liked his bedroom and had re-decorated it since the last inspection. Service users are able to maintain their independence and one service user was observed to prepare his tea and enjoyed it very much. He makes his own arrangements to see a chiropodist. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Service users care plans have been developed in a pictorial format but these will need some improving to ensure they cover their preferred daily routines. The weight of service users must be recorded every month. While it was good that the management of medication had improved it was found a member of the bank staff was administering medication and had not received any training. The manager must address this as soon as possible. A requirement from the previous inspection for an increase in staff during the evenings had not been addressed. Action must be taken to address this to ensure service users have wider opportunities for unplanned activities. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 7 The records of food eaten by service users must be recorded daily by staff demonstrating they are consuming a choice of meals. The kitchen needs to have different coloured chopping boards to maintain appropriate infection control practices in the kitchen. Staff were overdue fire training and the manager is reminded that this should be completed every six months. There are a number of policies and procedures provided by the organisation and it is recommended these include details of the local CSCI office when the CSCI should be contacted where there are issues around the welfare of service users. Visits from the representative of the organisation must be completed every month. The reports for these do not adequately documented comments from service users and staff about the management of the service. 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. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 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 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 Service users needs are re-assessed through the involvement of social workers but action is required to address any unmet needs identified by the service. How the service meets the needs of the current group of service users have greatly improved with a more positive approach from staff. Service users have individual contracts but these need updating to inform them what they are paying and what monies they are allowed to keep. EVIDENCE: The previous unannounced inspection identified a number of concerns around the protection of the service users and the poor working relationships between the manager and certain members of staff. The service users have endured a period of disruption since the suspension and eventual dismissal of two members of staff. In discussion with the manager she spoke of how the atmosphere with in the service had improved and that the service users were more relaxed and seemed to have developed more confidence in expressing their feelings. Relationships with the staff had also improved. The manager stated other staff were more responsible in addressing issues around poor practice. One member of staff commented she felt more accepted within the staff team and thought the service users were now freer to express their views. Two service users were present during this inspection including one who had little in the way of verbal communication. It was noticeable however, that the service user was more vocal than he had been during previous inspections and 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 10 was smiling a great deal more. A sample of his daily diary stated how during a night out at a Caribbean music event the service user started to dance something the manager stated he had never done before. One service user commented that he was happier where he was living describing it as homely and cosy. The service user was more outgoing than at the previous inspection and was very keen to show his large building being made from Lego bricks of which he has a keen interest. The third service user was out during the day and comments received prior to this inspection stated that he liked living in his accommodation and was well cared for by staff. While improvements have been made for the best interests of the service users there is still an outstanding issue around staffing levels during the evening. There is only one member staff on duty during the evening to three service users. This limits the opportunities for service users to have unplanned activities. An examination of one service user’s care record found that an assessment and new care plan had been drawn up by a social worker. The assessment identified the need for the service user to have 1:1 support during the evening but there was no conformation whether the Local Authority was addressing this shortfall. The manager stated she had written to the Team Manager for the social work team every month requesting additional funding but there had been no response. Letters seen on the service user’s file confirmed this. An examination of two service users records found that each one had new skills assessment completed. Observations made of staff interaction found the interactions to be friendly and supportive. Each service user has a contract in a picture format but the manager must ensure these are updated to reflect what they are paying for and how much spending money they are allowed to keep. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 How service users needs are to be met are set out in care plans that are being developed in a more accessible format for service users. Improvements are required to the care plans that reflect service users preferred daily routines. Service users have risk assessments in place ensuring staff are aware how service users are to be supported in the premises and in the community. Service users are encouraged to make decisions about their lives through weekly meetings. EVIDENCE: Two service users care records were sampled. These have information including objectives what progress had been made in meeting the objectives such as for example one service user to communicate more effectively using makaton. The manager had developed care plans in a pictorial format setting out what the service user could do and any assistance needed. The manager stated that so far one service user had responded to the picture format in a positive way. However, one did need more information regarding the individual’s personal care requirements such as for example their preferred time and day to have a shower and when they get up or go to bed. The care plans will need additional reference regarding service users daily routines and lifestyles. Each service user has a person centred plan, which indicated they 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 12 had been involved in their development and refers to their likes and dislikes. Further sampling found these had been reviewed since the last inspection. There were risk assessments in place including using equipment in the kitchen and for service users looking after keys to the front door and bedroom. A risk assessment was also in place for one service user being escorted in the community that stated 1:1 support was required from staff. Service users have a meeting every Sunday where they can discuss future activities and plan their menus. The minutes for these were now being printed making it easier to read. Service users are encouraged to make decisions about their lives. One example of this was for one service user who stated his wish during a recent medication review with his consultant, to manage and administer his own medication. The manager stated that since the last inspection all three service users have become more vocal in communicating their wishes, which she viewed as very positive. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16, 17 Service users with communication difficulties receive appropriate support to assist with their development. Service users have access to leisure activities in the community and are able to go on holiday as individuals and not as a group. Service users are encouraged to be independent with no unnecessary restrictions in place subject to individual risk assessments. Service users food intake records are not completed regularly to demonstrate they have eaten a varied diet. EVIDENCE: At the time of this inspection service users did not have any restrictions with regard to their daily routines. One service user was out during the day visiting his brother. Another was supported by a member of staff to attend a multi sensory activity called Relaxaway. An examination of service users records indicated that one service user had recently commenced an activity such as upholstery, which he commented how enjoyable it was. Another service user goes horse riding and attends a college where he takes part in musical and movement. The manager and a member of staff commented that since the last inspection the service user had required less support when at the college and was able to be left with other students without any problems with disruptive 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 14 behaviour and was more interested in joining in the activity. Since the last inspection two service users had been on holiday. One went to Blackpool while the other had spent their holiday in Minehead. The service user who went to Blackpool stated he chose his holiday destination and enjoyed it. He would like to go to London in the New Year. In discussion with staff and an examination of service users’ daily records there was indication of service users being involved in activities in the community such as shopping. One service user confirmed he had a key to his bedroom and for the front door. Since the last inspection a communication board has been set up for one service user who has limited verbal communication. This consists of photographs of activities involving the service user and of staff who are on duty each day. Observations at the time of this inspection found service users are encouraged to maintain their independence. One service user was observed to prepare his own tea while another was making himself a hot drink with support from a member of staff. The manager has introduced a picture format for the menus since the last inspection and it was noted a record was being maintained of food eaten by service users but these had not been completed on a daily basis. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users receive support with their personal care and choose when they require assistance. Service users have access to community and specialist healthcare services with or without the need for staff support. The system for medicine management has improved since the last inspection ensuring service users medication needs management. Despite this not all staff have received appropriate medication training that is potentially placing service users at risk. EVIDENCE: The service has an all male group of service users so appropriate gender care is provided. One service user stated he was able to get up and go to bed when he wanted to. An examination of daily records confirmed service users were able to have a lie in during the weekends. The daily recording also referred to where service users had received support with their personal care. Each service user has a movement and handling assessment that had been reviewed since the last inspection. Service users records confirmed they have access to local healthcare services such as dentist, optician, GP and chiropodist. One service user stated he made his own arrangements to visit a chiropodist. Further sampling confirmed service users had accessed specialist professionals including a Consultant Psychiatrist. One service user had participated in discussion with his psychiatrist of his wish to self administer his own medication. The manger 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 16 stated that plans for this were being developed with the Psychiatrist concerned. Service users have received yearly health checks from their GP. Two comment cards were received from GP’s prior to this inspection. While not making any specific comments about the service they had ticked yes to state staff communicated to them clearly and they understood the needs of the service users in their care. It was noted that the records for service users’ weight was not being recorded on a monthly basis. Any reasons why this has not occurred must be documented. An examination of service users care records indicated that each one had an individual Health Action Plan in line with the Department of Health’s Valuing People white paper. These covered when service users had treatment from various healthcare professionals during the past year. The management of medication had improved since the last inspection. An examination of the Medicines Administration Records found there were no gaps in recording. Balances of tablets from the previous four week MAR chart cycle were being carried over. Excess medication was being returned to the supplying pharmacist. A representative from the supplying pharmacist had visited the service prior to this inspection and found the management of medication to be acceptable. The majority of staff have completed accredited training in the safe handling of medicines. The manager has arranged for staff to receive MDS Training from the supplying pharmacist in January 2006. Written protocols were in place for the use of PRN medication including paracetamol and diazepam. In discussion with a member of staff it was discovered she had been administering medication without any training. The member of staff concerned was part of the bank staff and was mainly working for the organisation’s domiciliary care service. The manager stated that the manager for the other service informed her the staff member had been trained but would be placing the staff member on the MDS training in January 2006. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users complaints are listened to and are acted on by the manager informing them of the outcome of any investigation including action to be taken. Improvements have been made by the manager to ensure all staff protect vulnerable service users from bullying and abuse. EVIDENCE: The service had received one complaint from one service user since the last inspection. There was evidence on the service user’s file that the manager had provided a written response to his complaint outlining the action to be taken The service user was asked if he was satisfied with the outcome of his complaint and he was satisfied with the response from the manager. At the previous inspection a service user who had concerns over money going missing from his Post Office bank account had part of his money refunded. An examination of minutes of service users meetings showed that service users were reminded by the manager they could contact the CSCI if they had any concerns but it is expected that in future meetings, the manager and staff continues informing service users about the Commission and their role in investigating complaints if they wish to bypass the organisation’s complaints procedure. A picture of the Inspector was on display in the hallway. The previous inspection highlighted a number of serious concerns around the protection of vulnerable service users. Two members of staff had been dismissed since the last inspection due to poor care practices. Adult protection training had been provided for all staff since the last inspection along with training in physical intervention. An examination of staff meetings minutes indicated the manager had reminded staff about the Multi Agency Guidelines published by Birmingham Social Care & Health. Two staff interviewed stated they had read the guidelines and provided satisfactory responses to questions 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 18 regarding challenging poor practice. Each service user has a copy of adult protection guidelines that informs them of what the service will do in the event of any concerns being raised. Service users records for the management of personal allowances were examined. There were records in place for monies coming in, what had been spent and for what purpose. There was evidence of receipts for items of expenditure and each service user had a financial profile covering information around their benefits and who manages their financial affairs. There was evidence of two signatures during transactions but there were some gaps apparent on the individual personal allowance records. Each service user has their own bank account. The adult protection policy and procedure produced by Robinia needs an amendment to state that any concerns around suspected abuse to a service user should be notified to the CSCI verbally, although there is a procedure in place informing staff around the use of Regulation 37 notification that includes letting the CSCI know of any incidents of suspected abuse. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 Improvements have been made to the standard of cleaning and decoration to the premises giving service users a more homely environment. Practices with regard to infection control have also been improved maintaining service users’ health and safety. Service users have bedrooms that individually reflect their lifestyle. Service users have full access to the premises and are also able to use the bathing and toilet facilities. EVIDENCE: A tour of the premises had been undertaken and it was evident there had been an improvement in the standard of cleaning. New radiator covers had been installed throughout the premises. The dining room had been decorated with new dining room furniture in place. The lounge was clean and tidy. It has a TV set and video recorder. A service user was keen to show what work he did to re-decorate his bedroom with the colour of his choice. Action had been taken to level some of the paving slabs that were raised in the back garden. The light pull cords in the bathroom and toilet had been replaced. In discussion with the manager it was recommended she invited an infection control nurse to undertake an audit of the service’s infection control practices. The manager contacted the Health Protection Service in Birmingham and an appointment and a visit had been arranged for the following week of this inspection. Prior to publication of this report a copy of the infection control audit was sent to the 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 20 CSCI and it was noted the service had obtained a high score confirming it was maintaining a high standard in the control of infection. Two service users bedrooms viewed found these were individually personalised. A service user stated he liked his bedroom, as it was big enough for him to pursue his interest in building models out of Lego building bricks. Another service user had his own keyboard. Both bedrooms seen had wash hand basins although the seal underneath one wash hand basin was in need of repair. There is a toilet on the first floor and a toilet is also located in the bathroom that has a shower cubicle and wash hand basin. Liquid soap and disposable towels dispensers are in place in the toilet and bathroom. Suitable privacy locks are fitted to the bedrooms, toilet and bathroom. The current group of service users do not presently have any mobility difficulties and are able to access all parts of the premises. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Staffing levels continue not to meet the needs of the current group of service users. They limit opportunities for more spontaneous activities in the evening. Staff recruitment records meet the requirements of the regulations protecting service users interests. Staff receive regular supervision enabling them to undertake their duties effectively. The organisation offers and provides training to staff enhancing their development. Service users are supported by staff that have an understanding of their needs. EVIDENCE: At the time of this inspection there were three members of staff on duty during the morning with one member of staff covering the afternoon period and evening. There is still an outstanding requirement from previous inspections for an increase in staffing levels during the evening. The manager stated she had written to Birmingham Social Care & Health for an increase in funding for a service user to have 1:1 support. An examination of the service user’s record confirmed letters had been sent to the Team Manager. A member of staff stated she thought there could be more staff during the evening so that the service users had more activities. The pre-inspection questionnaire stated that 52 shifts had been covered by bank staff during the previous eight weeks prior to this inspection. Two members of staff, including a Team Leader have been dismissed since the last inspection following suspension over inappropriate care practices. Four 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 22 bank staff have been recruited and the manager stated she was interviewing for a full time care worker post. Observations at the time of this inspection found service users were being supported by staff that provided friendly and positive support. Two members of staff spoken with demonstrated a good understanding of the needs of the current group of service users. A sample of two staff recruitment records included a job application form, photo, CRB check, job description, contract, two references and other proof of identity documentation. Staff training records examined demonstrated training had recently been provided in topics such as first aid, manual handling, safe handling of medicines, food hygiene, infection control, food hygiene, physical intervention, autism and adult protection. Two members of staff had completed foundation training for the Learning Disability Award Framework. There was evidence of certificates of training completed and for NVQ qualification. Two members of staff stated they had completed NVQ Level 2 training and one was due to commence NVQ Level 3. Further examination of staff records indicated staff were receiving supervision every two months. Future training being planned was for the use of makaton. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 The Registered Manager has made improvements to the service that benefits the service users. Service users benefit from a relaxed friendly atmosphere, which they appreciate. The organisation must be more robust in ensuring service users views about the service are frequently heard. Service users interests are maintained through appropriate maintenance and storage of their records. Service users health and safety is being maintained with some improvements needed. The organisation has a range of policies and procedures, which will require some minor amendments to reflect current practice. EVIDENCE: The Registered Manager has worked hard to address a number of requirements since the last inspection. Comments and suggestions made were received positively. However, there are still some outstanding requirements that need addressing some, which should be addressed by the organisation. She stated that since the two members of staff had been dismissed there was a more positive approach from the remaining staff team. The service users seem to be more relaxed and more communicative. At the time of this inspection the 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 24 atmosphere was found to be friendly and relaxed with a service user and two members of staff commenting they could approach the manager if there were any problems. The manager was able to demonstrate her knowledge about the needs of the service users in her care and had completed training in physical intervention following the last inspection. This condition of registration will shortly be removed. A representative from the organisation had made visits to the service in September and October this year. It was of concern to note there had been no visits made for, June, July and August. There was little in the way of evidence that the service had been actively seeking comments and views from service users and staff. Given the concerns raised in the previous report about poor relationships between certain members of staff and the manager and how service users interests are being protected, these visits should have occurred on a monthly basis. Future reports completed by the representative must contain examples of service user consultation. The service has a range of polices and procedures. A number of these were in need of amending to provide details of the local CSCI office and it is recommended that the organisation amend these accordingly. A quality assurance report prepared by Robinia was examined and there were examples of questionnaires for service users, staff, relatives and social workers. There was no evidence that these had been used for the current group of service users. The organisation’s QA report tended have more in the way of staff and social worker comments with no comments received from the service users themselves only the use of pie charts. There was no breakdown of comments received from service users and their relatives for the Robinia group of services in the Birmingham & Solihull region. The records were generally up to date and locked in a secure facility. The manager ensured the staff records were available for inspection. An examination of health and safety records was found to be satisfactory. There was evidence to confirm the mains operated smoke detectors had been tested weekly and were recently serviced. The emergency lighting had been tested every month. There was a fire drill prior to this inspection, but it was noted staff were overdue fire training which the manager was reminded should occur every six months. Since the last inspection there was up to date documentation to confirm the worthiness of the gas equipment used on the premises. There was documentation to state that the wiring on the premises had been examined. Since the last inspection radiator covers had been fitted to all radiators on the premises and the paving slabs in the gardens had been made even to reduce the risk of service users and staff tripping. The kitchen was clean and tidy and a requirement from the previous inspection for the microwave oven to be cleaned to an acceptable standard had been 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 25 addressed. It was noted the chopping boards being used in the kitchen were in need of replacing and there was a wooden one being used that is not appropriate for food preparation. A daily record for the temperature of the refrigerator and freezer was being maintained. There is a risk assessment for the premises but the manager must ensure this incorporates the garden and the front of the premises. At the time of publication of this report the manager provided documentary evidence confirming that the hard wiring for the premises had been tested and inspected. The accident book was examined and there were three accidents since the last inspection. The manager has informed the Commission of incidents affecting the welfare of service users via Regulation 37 notification. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 26 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 N/A 3 2 N/A 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 N/A Standard No 24 25 26 27 28 29 30 STAFFING Score 3 N/A 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 N/A 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 54 Brookvale Road Score 3 2 2 N/A Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 N/A DS0000043666.V260228.R01.S.doc Version 5.0 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33YA3 Regulation 12(1) 18(1)(a) Requirement Timescale for action 22/01/06 2. YA5 5(2)(b) 3. YA6 15(1) The Registered Person must ensure that appropriate staffing levels are maintained during the evening to enable wider opportunities for service users to participate in activities, but to also provide adequate cover in the home. Outstanding Requirement Timescale 24 January 2005 & 15 July 2005 not met and is carried forward. The Registered Person must 22/01/06 ensure service users contracts are updated to provide up to date information as to what is being charged and how much they are allowed to keep for personal expenditure. The Registered Person must 22/01/06 ensure service users care plans state how service users personal care requirements are to be met. They must also set out their preferred daily routines. 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 28 4. YA17 16(2)(i) 5. YA19 12(1) (a)(b) (2) 13(2) 6. YA20 7. YA26 23(2)(b) 8. YA33 18(1)(a) 9. YA39 26(1)(4) (a)(b) 10. YA42 13(4) The Registered Person must ensure service users’ food intake charts are completed daily. The Registered Person must ensure service users’ weight is recorded every month. Any reason why this has not been done must be documented. The Registered Person must ensure that all care staff working in the home receives appropriate medication training. The Registered Person must ensure that the seal underneath the wash hand basin in the one of the service user’s bedroom is repaired without delay. The Registered Person must ensure that appropriate staffing levels are maintained during the evening to enable wider opportunities for service users to participate in activities, but to also provide adequate cover in the home. Outstanding Requirement Timescale 24 January 2005 & 15 July 2005 not met and is carried forward. The Registered Person must ensure that visits by the representative of the organisation occur every month and ensure service users and staff are able to comment about life in the home. Reports from these visits must be forwarded to the Commission. Outstanding Requirement 15 July 2005 not met. The Registered Provider must ensure it purchases new coloured chopping boards for the kitchen. 22/12/05 22/12/05 22/01/06 22/12/05 22/01/06 22/01/06 22/12/05 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 29 11. YA42 13(4) The Registered Person must ensure the risk assessment for the premises includes the front and back garden. The Registered Person must ensure all staff receives up to date fire training, which should occur every six months. 22/01/06 12. YA42 13(4) 23(4)(d) 22/12/05 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 YA40 Good Practice Recommendations It is recommended that the Registered Person ensures the following policies and procedures of Robinia clearly state when the CSCI should be contacted including details of the local CSCI office: - Complaints - Accidents - Adult Protection - Physical Intervention - Whistle Blowing - Medication (Reporting medication errors) 54 Brookvale Road DS0000043666.V260228.R01.S.doc Version 5.0 Page 30 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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