Inspection on 24/01/07 for 58 Worlds End Road

This inspection was carried out on 24th January 2007.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

58 Worlds End Road 07/02/08

58 Worlds End Road 17/02/06

58 Worlds End Road 26/08/05

58 Worlds End Road 17/12/04

58 Worlds End Road 29/07/04

58 Worlds End Road 18/02/04

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 Worlds End Road, 58 Handsworth Wood Birmingham West Midlands B20 2NS Lead Inspector Gerard Hammond Unannounced Inspection 24th January 2007 12:15 Worlds End Road, 58 DS0000016931.V320155.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 Worlds End Road, 58 DS0000016931.V320155.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. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Worlds End Road, 58 Address Handsworth Wood Birmingham West Midlands B20 2NS 0121 523 5493 F/P 0121 523 5493 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.milburycare.com Milbury Care Services Limited Ms Elizabeth Brown Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years. To accommodate one named person with a physical disability, subject to regular review of her care needs. 17th February 2006 Date of last inspection Brief Description of the Service: 58 Worlds End Road provides accommodation, care and support for three adults with learning disabilities. The house is a domestic scale, semi-detached property situated in a well-established residential neighbourhood in the Handsworth Wood area of Birmingham. There is a range of community facilities within the immediate locality, including shops, places of worship, GP surgery and parks. Main public transport routes are within walking distance. On the ground floor of the house, there is a lounge to the front, and a kitchen and separate dining room at the back. There is also a laundry room, an assisted bathroom with w.c., and one residents single bedroom on this floor. Upstairs are two further bedrooms, another bathroom with w.c. and a small room used as an office. To the rear of the property is an enclosed garden with ramped access and handrails and small paved area. The drive at the front of the house can accommodate one vehicle, but there is parking on the road outside. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered from a range of sources prior to the visit being made to this service. These included previous inspection reports, service history and the pre-inspection questionnaire and incident reports completed by the Manager, and reports submitted on behalf of the Registered Provider. Direct observation and sampling of records (including personal files, care plans, safety records and other documents) were also used for the purposes of compiling this report. The Inspector was able to meet with all of the residents during the course of the visit. Unfortunately, their communication support needs and level of learning disability meant that it was not possible to seek their views directly. The Manager was formally interviewed and the Inspector was able to meet with two other members of staff. A tour of the building was also completed. Following the inspection visit, the Inspector was able to speak with a family friend of two of the residents by telephone. Thanks are due to the residents and staff team for their hospitality and support during the inspection visit. What the service does well: What has improved since the last inspection? What they could do better: Managing residents’ care could improve by setting goals better. These should show clearly what is being aimed at and how to do it. They should also say when this should happen by. Opportunities for people to communicate need to be increased. The good work already done with objects of reference needs to be built on. The quality of social and leisure activities that people currently enjoy needs to improve, together with the way in which staff keep a record of Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 6 such things. Staff training and work towards gaining qualifications is in need of some attention, and the number of staff available to support residents also needs to be looked at. The Manager must make sure that safety checks get done at the right times, and that a full record is kept of these. 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. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 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 Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ care needs have been properly assessed, and opportunities were provided to come and see what the service has to offer before making a decision to move in. EVIDENCE: Since the last inspection, one resident has moved to another home and two new service users have moved in, following the closure of their previous home. An examination of their personal files provided evidence of a programme of supported introductory visits before they moved in. The service users are brothers and have lived together all of their lives. A member of staff from their previous home, (which was run by the same organisation) has transferred to Worlds End Road so as to promote some continuity of care. The Manager reported that both men have settled in well. A detailed ELSI (Everyday Living Skills Inventory) was present on files examined, giving a comprehensive statement of individuals’ strengths and support needs. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ care plans accurately reflect their care needs, but need further development so that they are more person-centred and include more effective goals. Doing this should make plans better working tools, and improve people’s care. Service users are supported to make choices and decisions within the limitations of their levels of understanding and learning disability. Development of communication opportunities could improve this further. Risk taking is encouraged responsibly, but clearer links still need to be established between some assessments and relevant care plans. This will make it clear how decisions have been made and guide future planning better. EVIDENCE: Service users’ care plans were sample checked. It was noted that the two new residents’ plans, transferred from their previous home, were comprehensive Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 10 and gave detailed guidance about how support should be given. There was evidence on files of efforts to develop person centred approaches. A PersonCentred Plan book had been started, but it is not easy to see where this is leading. It may be that the staff team needs additional training and support to make the best use of these new “tools”. Within the current care plan format there is room for setting short, medium and long-term goals. One entry read, “continue with home skills”, but didn’t say what this involved, who was going to do it or when it was going to be done by. Another said, “monitor weight”. It is suggested that this is not a goal in itself, but possibly an objective for meeting the goal, which might be the promotion of healthy eating, or the maintenance of good health. Again, (as with person centred planning) it may be that the team would benefit from support to learn how to set goals appropriately. Key features should be that outcomes can be measured, and time limits set. It was also noted that, in this instance, no long-term goals had been set. Goal setting should also form an integral part of individual person-centred plans. Evidence was also seen that some progress has been made on work to promote residents’ communication opportunities, and this needs to be taken further (see also next section “Lifestyle”). Communication passports need to be updated and developed. It has previously been reported that attention needs to be given to information management in individuals’ care records. It has to be acknowledged that the complex nature and range of residents’ care needs means that there is always going to be a substantial volume of material to be organised. It is not always easy to present such records in a “user-friendly” way. It was noted however that on one person’s file the care plan index did not correspond to what was actually on the file, and that some risk assessments were not cross-referenced to the relevant care plans. Attention to simple details such as these would improve access to important information, by making it easier and quicker to find. However, risk assessments were generally in place, and demonstrated that attention had been duly given to identifying hazards and devising appropriate control measures. Residents’ communication support needs and levels of learning disability mean that their capacity to make choices and decisions is limited to fairly basic things. As reported above, efforts have been made to improve communication opportunities, and staff were directly observed offering choices about what to eat and drink, and activities, throughout the course of the visit. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for service users to take part in appropriate activities currently appear to be limited, and recording to support this needs to improve. This is important in order to show how choices have been made and why people do the things they do. Residents’ personal circumstances mean that opportunities for family contacts are restricted, but some thought should be given to how other social contacts might be developed. Service users have access to a balanced and varied diet and enjoy their food. EVIDENCE: It was noted that the standard of recording in relation to service users’ activities is currently poor. One person’s activity plan for the week included (for each day) “bath, choice of clothing & breakfast”. He has two sessions at a local college during the week, and other scheduled activities are going out for lunch, tidying his bedroom, assisting to make lunch and tea, personal shopping and local walk or drive. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 12 Records show that staff use “objects of reference” to support and promote communication opportunities and making choices. These include showing the service user a towel to indicate taking a bath, a CD for playing music, a backpack for going to college, car keys for going out in the car, bus pass for the bus, a wallet for doing personal shopping, and so on. The guidance suggests showing two objects to offer choice. This was not directly observed. However, staff reported that they had had some success with using these. It should be acknowledged that residents’ complex and high-level support needs may mean that engaging them in purposeful activity is not a simple task, particularly where, for example, an individual’s attention span is very short. It is currently difficult to assess fully the quality of residents’ activity opportunities because the recording to support this is so limited. There are no obvious links between what people do and their assessed needs and care plans. Conversations with staff indicated that they do try and ensure that residents go out each day, so as to access local amenities. They were directly observed doing this during the course of the visit. It may well be that residents are currently enjoying more opportunities than the records show, and staff need to understand why it is important to maintain a full record. At the moment, activity opportunities appear limited and somewhat haphazard. While it may be difficult (and possibly undesirable) to have a fixed activity programme, it is important that there is some structure to how these are planned, and that activities undertaken can be seen to be purposeful. This can be achieved by linking activities to residents’ agreed goals. Service users’ activity opportunities are a prime indicator of the quality of life they enjoy. The issue of activity recording is one that has been raised at previous inspections. The Registered Manager must ensure that all staff are aware of their responsibilities to keep appropriate records, and understand the purpose and value of so doing. The Registered Provider should also ensure that the staff team is properly supported and trained to meet the assessed needs of the people in their care. This must take into account residents’ specialised and complex needs. The two “new” residents do not have any known relatives, but a friend of their late mother keeps in touch and shows an interest in their welfare. The other resident has a relative living locally, but contact is very limited. While staff have no control over individuals’ personal circumstances, efforts should be made to try and widen residents’ social circles so as to develop opportunities for alternative relationships. As things stand, residents appear to have little opportunity for interaction with other people apart from care staff. Records of meals were generally complete, and showed that residents have plenty of variety and a diet that is balanced and nutritious. However, it is recommended that “takeaway” should say what this was, and “packed lunch” Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 13 should show what was in it. Food stocks were examined: these were ample and included fresh fruit, vegetables and salad. Residents were observed taking their evening meal in the dining room. This was quiet and unhurried, and they clearly enjoyed their meal. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 14 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. Service users’ basic personal care needs are well met and they are properly supported to make and keep general healthcare appointments. However, healthcare could be improved by positive development of health action planning. Though medication practice is generally satisfactory, it is important that the way in which it is stored is carefully monitored, to ensure residents’ safety. EVIDENCE: Interactions between residents and members of staff were directly observed. Support and encouragement were given with warmth, friendliness and respect. Service users’ personal appearance and grooming provided evidence that they are in receipt of a good standard of basic personal care. Care plans contain good information about individuals’ preferences and how they like to be supported. Records also provided evidence that residents are assisted to access primary and specialist healthcare, according to their needs. There were records of appointments and referrals to the GP and other members of the wider multidisciplinary team, including District Nurse, Consultant Psychiatrist, Ophthalmologist, Dentist, Chiropodist and Speech and Language Therapist. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 15 One resident is diabetic and insulin dependent. This is administered by the District Nurse. His care plan includes dietary guidelines and a record of checks on his blood sugar levels. He is also epileptic, and appropriate management guidelines are in place. There is information on file about Fragile X Syndrome, but no analysis of how this relates to him personally. It is recommended that this information is studied and used to inform his care plan more specifically. A new format has been introduced for Health Action Planning. Currently this is in the assessment phase, and these should now be further developed in order to make residents’ healthcare more proactive. Accident records were examined, and it was noted that, in some instances, reports required under Regulation 37 (Care Homes Regulations 2001) had not been submitted. The Manager must ensure that reports are completed and sent to CSCI as appropriate. It is recommended that a prominent note be placed on the Accident Book to this effect. The Boots Monitored Dosage System (MDS) is in use in the home. None of the residents is able to take responsibility for his or her medication. The Medication Administration Record (MAR) was examined and had been completed appropriately. Files contained copies of prescriptions and medication records included service users’ photographs, information on prescribed medicines and written protocols for PRN (“as required”) medication. It was noted that the record of checks on the temperature of the medication fridge contained a number of gaps. This is used to store the insulin, and it is essential that this be kept at the correct temperature to ensure its efficacy. The Manager must ensure that checks are carried out every day. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 16 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. It is difficult to assess fully whether or not service users consider that their views are listened to and acted upon, due to their learning disabilities. General practice protects service users from abuse, neglect and self-harm. EVIDENCE: No complaints have been received in respect of this service. Previous reports indicate that an appropriate complaints policy and adult protection policy (linked to local multi-agency guidelines) are in place. Formal complaints procedures have no relevance to the people living in this house, due to their communication support needs and learning disability. Service users are dependent on the vigilance of staff that look after them, and their sensitivity to changes in demeanour or behaviour, as indicators that something is amiss. It was noted that personal files had a section dedicated to “How I complain” that includes information about how individuals communicate they are uncomfortable or unhappy. Staff spoken to were able to demonstrate an appropriate understanding of the different types of abuse, and what they would do if they suspected that abuse had taken place. Records show that all staff have done training in the protection of vulnerable adults from abuse. Sampled recruitment records also show that appropriate checks have been carried out with the CRB (Criminal Records Bureau) prior to commencement of employment. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a house that is clean, comfortable and homely. Individual rooms are personal, toilet and bathroom facilities are adequate, and shared spaces sufficient for the number of people living in the house. Some areas of the house now require attention, so that the quality of the environment can be maintained. EVIDENCE: 58 Worlds End Road is a domestic scale semi-detached house. The property is generally well maintained, with fixtures and fittings of a good standard. Residents all have single bedrooms; two of these are on the first floor and one downstairs. Each room is individually styled, and personal possessions and effects in evidence. Staff have supported residents to furnish their rooms as they like, and to obtain specialist equipment for sensory stimulation and calming / relaxation. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 18 There is an assisted bathroom with toilet on the ground floor, and a further bathroom with toilet upstairs. These are adequate for the needs of the current service users. Shared spaces include a comfortable lounge at the front of the house, and a good size dining room at the back. Both rooms have television sets in them. At the time of the last inspection, requirements were made in respect of kitchen refurbishment, cleaning / repair of the bathroom extractor fan, and repair / replacement of the sluice washing machine. All of these have now been met. In particular, the kitchen has been refitted, and this is a significant improvement. It was noted that the dining room is now beginning to show signs of wear and tear and would benefit from refurbishment. Woodwork at the front of the house needs repainting: in its current state it detracts from the overall look of the property. Staff work hard to keep the house clean comfortable and homely, for the benefit of the residents. A good standard of hygiene is maintained throughout. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing complement should be reviewed to ensure that sufficient numbers of support workers are available to meet service users’ assessed needs. A training and development plan is required and action taken to improve the qualifications of the care team, to ensure that residents benefit from being cared for by properly trained staff. Service users are protected by the home’s recruitment practices. EVIDENCE: Duty rosters show that there is normally two support staff on duty. Given the high level support needs of the current residents, and coupled with the fact that care programmes for all of the residents are predominantly home-based, this does not seem adequate. The staff complement should be reviewed in accordance with individuals’ assessed care needs. Information shown in the response to the PIQ shows that only 30 of the current staff team hold qualifications at NVQ level 2 or above. This falls well short of the National Minimum Standard. Available information shows that only one member of staff has completed LDAF (Learning Disability Awards Framework) accredited training. A training and development plan is required for the home. It is Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 20 important that the Manager has an overview of the training needs of the staff team. Individual staff members have records on their personal files, and it is recommended that this be transferred onto a spreadsheet, so as to present the “global” picture. The plan should show, for each member of staff, training done to date and qualifications gained. It should highlight any gaps (including “refreshers”) and indicate when outstanding training is to be delivered, and by whom. The Manager may need some support to become confident about using a spreadsheet. In view of the support needs of these service users, some priority should be given to providing training in autism and augmented communication. Recruitment records were sample checked. Completed application forms, written references, pre-employment checks and evidence of induction were all present as required. Arrangements for formal supervision have improved since the last inspection, and these are now generally taking place monthly. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 21 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 home is generally run to an acceptable standard, but some issues require attention so as to ensure the health, safety and welfare of service users and staff. Quality assurance systems should be reviewed to demonstrate how judgements about service users’ views have been arrived at. EVIDENCE: The Manager is qualified to NVQ level 4 and holds the Registered Manager’s Award. At the last inspection a requirement was made that the Manager forward copies of her certificates when she received them, and this has now been done. Staff report that she is approachable and that they are comfortable in bringing any matters of concern to her attention. The Registered Provider has produced its annual report of quality assurance and monitoring. The report is an analysis of service users’ levels of satisfaction across a range of activities (catering / food, personal support / care, daily Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 22 living, your home, management of support service and information), allocating “scores” in each area. In view of the communication support needs and level of learning disability of the service users, it is assumed that someone else has had to decide how this can be completed. The quality assurance system should be reviewed so that the report can demonstrate more clearly how judgements have been made and perhaps to say who made them. It has to be acknowledged that this presents very particular challenges, and the task to date has been carried out in good faith, but the end result should be more transparent. It was noted that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) have been completed during the year, but that the frequency has not been up to the required standard. The Registered Provider must ensure that these are carried out each month as appropriate. Safety records were sample checked. Certificates for electrical hard wiring, gas safety and portable appliance testing were all in date. The specialist bath has also been serviced, and the fire alarm and fire-fighting equipment. The workplace risk assessment has been reviewed, and the COSHH store was secure. The records for temperature checks (fridge / freezer, water outlets) and testing of the fire alarm and emergency lighting systems all had a number of gaps in them. Core temperatures of cooked food had been checked and recorded, as previously required at the last inspection. The Registered Manager must ensure that all required checks are carried out at the appropriate intervals, and a complete written record maintained. A copy of the Environmental Health Officer’s most recent report was seen. Requirements made have been addressed by the kitchen refit, though the need to maintain correct fridge temperature was also included. Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 23 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 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 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 2 X X 2 X Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 (1-2) Requirement Care plans should be developed to include individuals’ personal goals as indicated in the main body of this report. Whole plan reviews should take place at least every six months, with written records showing who takes part and how decisions are made. (Partially met) Develop communication passports and expand the use of objects of reference, so as to improve service users’ communication opportunities. Cross-reference all risk assessments to the care plan(s) to which they relate, and vice versa. (Outstanding since 30/04/06) Timescale for action 30/04/07 2. YA7 12 (2) 30/04/07 3. YA9 13 (4) 30/04/07 Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 25 4. YA12 YA13 YA14 16 (2m-n) 5. 6. 7. YA15 YA19 YA20 16 (2m-n) 12 13 (2) 8. YA28 23 (2b) 9. YA32 18 (1c) 10. YA33 18 (1a) 11. YA35 18 (1c) Recording relating to residents’ activity opportunities should be developed to indicate what the purpose of each activity is, and to include sufficient detail to support judgements about how successful it has been in achieving that purpose, so as to inform future planning. Activity opportunities should be clearly linked to individuals’ assessed needs and care plans. (Outstanding since 30/04/06) Actively seek to expand service users’ social and leisure opportunities. Develop Health Action Plans for each service user Ensure that the temperature in the medication store fridge is tested each day, and a written record maintained. Redecorate the dining room and exterior woodwork including the main door at the front of the house. Ensure that at least 50 of staff have achieved or are working towards qualifications at NVQ level 2 or above. Review the staff complement and ensure that sufficient numbers of staff are available to support service users in accordance with their assessed needs. Forward to CSCI a current staff training and development plan as indicated in the main body of this report. 30/04/07 30/04/07 30/04/07 25/01/07 30/04/07 30/04/07 30/04/07 30/04/07 Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 26 12. YA39 26 24 (2) 13. YA42 13 (4c) The Registered Provider must ensure that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are carried out at least once every month. The system for quality assurance and monitoring should be reviewed to show how judgements about service users’ views have been reached. Ensure that all safety checks are carried out at the appropriate intervals, and a full record of each test maintained. 30/04/07 29/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA7 YA19 Good Practice Recommendations Seek guidance to improve ability to develop agreed goals with service users. Seek professional support to develop service users’ communication opportunities (e.g. Speech and Language Therapy Service) Refer to local Community Nurse (Learning Disabilities) for support in developing Health Action Plans Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 27 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 Worlds End Road, 58 DS0000016931.V320155.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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