Inspection on 07/02/08 for 58 Worlds End Road

This inspection was carried out on 7th February 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

58 Worlds End Road 24/01/07

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 Kath Strong Unannounced Inspection 7th February 2008 10:00 Worlds End Road, 58 DS0000016931.V356527.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.V356527.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.V356527.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 Ltd Ms Elizabeth Brown Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Worlds End Road, 58 DS0000016931.V356527.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. 24th January 2007 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 home is registered for four persons but this would involve two people sharing a bedroom. The organisation does not intend to seek a fourth occupant. The house is a domestic style, semi-detached property situated in a wellestablished and pleasant 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 rear. There is also a laundry room, an assisted bathroom with toilet and wash hand basin, as well as one person’s single bedroom on this floor. Upstairs are two further bedrooms, another assisted bathroom with toilet and wash hand basin, and a small room, which is used as an office. To the rear of the property is an enclosed garden with ramped access with handrails and a small paved area. The drive at the front of the house can accommodate one vehicle; there is available parking on the road outside. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out; this is to enable the inspector to obtain an accurate picture of the standards of the services provided. On the day of the visit, the home had three people living there. Assistance with the inspection process was provided by the manager. At the conclusion feedback was given to the manager. One Immediate Requirement was made. This concerned inadequate daytime staffing levels. Information was gathered from observing people who reside at the home. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A full tour of the premises was carried out. One of the three care plans reviewed was case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people and the standards of care provision. Prior to the visit the home had completed the annual quality assurance assessment and returned it to us. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. Due to communication problems people who live in the home were not requested to complete questionnaires. The focus of inspections undertaken by us is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: People are well cared for and receive the personal and healthcare they need to promote their health and wellbeing. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 6 The premises have been adapted, furnished and decorated to suit the physical abilities and age range of the people who currently reside there. The home is warm, comfortable and homely and bedrooms are personalised to the extent that is preferred by the occupant. There is evidence that people are supported and assisted in keeping appointments with healthcare professionals. Staff appear to take a proactive role in maintaining peoples health. The manager is committed to providing the highest possible standard of services and the health and safety arrangements are considered to be paramount. These actions indicate that people are kept well and injuries are prevented as far as practically possible. No complaints have been received by the home or us. This suggests that people are receiving good standards of care and that their representatives are content with what they see. The manager is assisted by two senior support workers in the day to day running of the home. Some staff have been employed for a considerable period of time; this ensures that people living in the home have continuity of care. What has improved since the last inspection? Since the last inspection the manager has reviewed and re-written the care plans. These are now extensive; provide clear information about the individual and staff guidance about what needs to be done to ensure peoples welfare. The home has demonstrated that where an allegation of abuse is made that it would be treated seriously and dealt with appropriately. Most of the requirements made at the last inspection have been met. This indicates that the home is constantly striving to make improvements for the benefit of people living there. The amount of staff training has increased and the majority of staff have either completed or are in the process of finishing courses. This will give them the knowledge and skills to carry out their roles effectively. The dining room has been redecorated to provide a pleasing environment for people to have their meals. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. With the exception of fee rate details the home supplies adequate written details to prospective users of the service to enable them to make an informed decision about moving into the home. Pre-admission assessment carried out indicates that the home is able to meet a persons needs at the time of admission. EVIDENCE: The statement of purpose is comprehensive. A copy of the service user guide is given to people or their representatives who are considering a placement at the home. Each paragraph is accompanied by pictorial explanations to assist people in understanding the contents of the document. This is viewed as being good practice. The manager was advised that the service user guide should also include the fee rate and details about any contributions made by other agencies. Information concerning services that are not included in the fee rate should also be included. There have been no new admissions for some time. The methods used for the last two admissions indicated that senior staff gathers sufficient information to Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 10 determine whether the home can meet the individuals needs. The manager advised that the following actions are usually taken: • Comprehensive pre-admission assessment carried out by the manager • Obtaining reports from external professionals • Numerous visits to the home by the prospective resident to determine how they interact with the people already living in the home. Both the individual and staff need to be confident that good relationships will develop with between people. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive; they provide staff guidance and input that is required to enable people to meet their personal needs. People are supported in making their own decisions and in taking informed risks. EVIDENCE: Each person has a written care plan. This is an individualised plan about what the person is able to do independently and specifies what assistance is required from staff in order for them to maintain their needs and preferred lifestyle. All three care plans were reviewed and one was case tracked. Since the last inspection the manager had reviewed and re-written the care plans. These were found to be extensive and provided good staff guidance about what they need to do to ensure that peoples’ needs are met. The manager should be commended for the efforts that she has made with care planning. The files Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 12 were found to be very neat and indexed for ease of access. Each person had a file concerning personal and recreational needs, a file about their healthcare needs and another file that provided more detailed information about recreations and staff recordings. Information included a personal profile about the person and their background and relatives and friends. They described the person’s preferred daily routines and when staff assistance is needed to complete them. They appeared to be person centred and included goals to achieve to improve peoples independence. There was evidence that people are encouraged and supported in making decisions within their limitations of understanding. Files contained information about peoples contact with family and friends. There was good information about peoples’ food likes and dislikes. People living in the home are encouraged to do things for themselves within their capabilities. Staff were observed to be very patient and slowly explained reasons for the action that was about to take place. All care plans were accompanied by a risk assessment. These included personal care, health care needs, activities within the home and going out into the community. This is viewed as being good practice in minimising the risks of accidents and injuries. One person was observed to constantly wander around the home and garden requiring lots of supervision. Staff were diligent in carrying out this task and did not make any attempts to restrict the individual. A few minor shortfalls were found in the care plans as follows: • The daily routine for one person did not extend beyond lunchtime, this needs further development • The mobility assessment for one individual fails to mention that he needs to use the handrail when going up or down stairs • Although there was lots of information a care plan needs to be developed for the person who is an insulin dependent diabetic. The manager was advised that with the exception of the above that the care plans are very comprehensive and demonstrate how peoples needs were being met. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples’ independence and individuality is being compromised by lack of staff to support them in leading a meaningful lifestyle. People receive a varied and wholesome diet that takes into account their personal preferences. EVIDENCE: The activities programme of each person was checked. They failed to provide sufficient variation to ensure that people lead a meaningful lifestyle. For instance all included tasks within the home, music, board games, one walk per week and a visit to the local shops for personal shopping. There were some variations such as sensory sessions for one individual and another is assisted in attending church services. When asked about the limitations imposed on people the manager reported that the programmes had been devised according to available staff to support people. The last inspection identified Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 14 the same problem. A requirement was made for a staffing review to be carried out by 40/04/07. The organisation failed to respond. One person attends college once a week and another goes twice a week, both require to be accompanied for the outward and return journeys. When people go out into the community they need to be accompanied, as does the individual who attends church services. This impacts on remaining staff available to cater for the needs of the people who are still in the homes during those periods. Review of the recordings made by staff of recreations that have been achieved evidenced that the programme is not always being met. This suggests that there were not enough staff rostered to enable them to offer and support people in leading an interesting and quality lifestyle. It should be acknowledged that people’s complex needs and high level of support needs may mean that engaging them in purposeful activity is not a simple task. This is impacted by people’s short attention span. One person constantly wanders around the home and garden requiring supervision. A fifteen minute observation was carried out in the lounge. The manager was busy in the dining room; she was overheard making telephone calls. The second staff on duty was in the lounge writing reports in peoples care plans. The only interactions noted were when she asked each person if they were OK. People were not receiving the input and stimulation they need. The care plans indicated that effective means of communications had been developed for each person. The information indicated that varied and appropriate systems were in place to enable the most efficient means of communicating with individuals had been developed. The home appeared to have an open policy in respect of visiting. Files contained information about maintaining relationships with families and friends. The capacity of two people in making decisions were noted to be limited. Staff appeared to be able to communicate well with people. Food records were being maintained that included what each person ate and the quantity. The records indicated that people were being offered good variation that took into account peoples likes and dislikes. The kitchen stocks included fresh fruit. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ healthcare needs are being identified; recorded and systems put in place to promote their health and wellbeing. The management of medications are good; this means that people are receiving their prescribed medications correctly. EVIDENCE: All three care plans were seen and they contained good information about how peoples’ needs should be met. Assessments about health were being carried out and a care plan subsequently developed. There was evidence of regular sessions with external professionals such as GP, chiropodist, optician, dentist and district nurses. Records also indicated that people access to specialist healthcare professionals such a psychiatrist, speech and language as well as input for one person who has a particular syndrome. All care plans pertaining to healthcare were accompanied by a risk assessment, which is viewed as being good practice in minimising risks of illness and injuries from occurring. As discussed previously, a care plan in respect of the person who is an insulin dependent diabetic was in need of Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 16 being developed. Accident records were being completed and stored in the individual’s file. Records indicated that health assessments were being updated monthly to ensure that they were accurate. Charts for monitoring some physical conditions were in place for staff to access as required. Peoples’ healthcare needs were being well met. The management of medication was found to be good, meaning that people receive their prescribed medication correctly. Drugs were being audited upon receipt from the pharmacist to ensure that the dispensing methods were accurate. Copies of prescriptions were being kept by the home to enable them to complete the auditing process. The MAR (medication administration record) charts were appropriately completed. The drug fridge temperature was being recorded daily. When instructions on the MAR charts are altered or added to by staff they must be signed by two people to confirm that the changes are correct. The home maintains its own records of medications; these were being regularly reviewed. The use of sticky labels to change records must cease with immediate effect; this was brought to the managers attention . Files contained good information about peoples’ health conditions and what staff should observe for. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current client group are dependent on staff to act as advocates when they are not happy with the services. The arrangements suggests that appropriate action would be taken where concerns are observed. Staff practices protect people living in the home from risks of abuse. EVIDENCE: The written complaints procedure was seen and appeared to supply sufficient advice about what the complainant should do and the anticipated outcome. The home is advised to produce the document in an easy use format for the assistance of the people who use the service. No complaints have been received by the home or us since the last inspection. The home has a complaints log; the headings suggest that upon receipt of a complaint that it would be dealt with appropriately. The home uses the Department of Health’s Practical Guide to Protection of Vulnerable Adults and was also noted to also have a copy of our Safeguarding Adults Protocol and Guidance. An incident that had occurred confirmed that the home would take correct action when abuse is reported or suspected. Staff have received training in this aspect of care. The home holds small amounts of personal monies on behalf of the people who live there. The storage, transactions and recordings confirm that the home Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 18 operates a robust system. This indicates that people are protected from risks of financial abuse. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 and 31. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with comfortable, warm, homely and hygienic accommodation that is appropriate for the age and preferences of the current client group. EVIDENCE: The home is a two storey domestic style semi-detached house. The property is generally well maintained, tidy and clean. The fixtures, fittings and furniture are of a good standard and are in keeping with the age group of the people living in the home. There is a lounge, separate dining room, kitchen and a laundry room. The dining room has been redecorated since the last inspection. Both the lounge and dining rooms include a television and music centre. The ground floor also includes a bathroom containing an assisted bath, wash hand basin and toilet. There are three bedrooms, one situated on the ground floor and two on the first floor. The first floor also has an assisted shower room with wash hand Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 20 basin and toilet. A small office is also located on the first floor; medications are stored in this room. The enclosed rear garden is accessed via a ramp. It has a small paved area as well as a lawn. The numerous trees and bushes around the perimeter results in good seclusion to enable to relax in privacy. Bedrooms were noted to have been nicely decorated and individually styled; personal possessions were in evidence. One room contained items to promote sensory stimulation to assist the occupant in relaxing. Staff work well in maintaining a clean and safe environment for people to live in. People were being encouraged to assist by carrying tasks such as clearing the dining table, tidying their bedrooms and polishing furniture. These practices promote peoples ability to maintain and learn daily living skills. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are unsafe; this puts people living in the home and staff at risk of harm. Staff receive the necessary training to give them the knowledge and skills to carry out their roles effectively. EVIDENCE: Copies of four weeks of current duty rosters were obtained. They confirmed that only two members of staff would be routinely allocated to care for three people, two of whom have profound problems requiring close observation. Twice a week an escort service is provided for the outward and return journeys to college, which can take up to one hour to complete. During these periods there is only one carer left in the premises to care for one or two people. This is considered to be unsafe. An Immediate Requirement was made for safe staffing levels to be ensured at all times. Shortly after the inspection we have received information that a third carer will be rostered to ensure safe staffing levels and assist with appropriate recreations for people. The action taken needs to be sustained in order to prevent further action being taken by us. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 22 Either permanent staff or bank staff fill in gaps when staff are absent or on annual leave. The manager advised that agency staff are not used. This practice ensures continuity of care for the benefit of the people living in the home. Review of a sample of staff files including the latest recruit was carried out; they were found to be satisfactory. This confirms that the home operates a robust system when recruiting staff for the protection from harm of the people living there. Relevant pre-employment checks are carried out and two written satisfactory references are obtained before a position is confirmed. Newly recruited staff are expected to undertake LDAF (learning disability awards framework) induction course to give them the basic skills to work with people in this sector. Of the nine staff in post 56 have successfully completed NVQ level 2 or equivalent to give them the additional skills to provide the specialist support that people require. Further training includes, food hygiene, adult protection, health and safety, epilepsy and computer training. Some staff were currently undertaking health and safety at the time of the inspection. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Monthly unannounced checks on the standards services provided are not being carried out often enough. The health and safety arrangements ensure that people are protected from risks of accidents and injuries. EVIDENCE: The registered manager had been at the home for a considerable period of time. She possesses the knowledge, skills and experience to effectively manage the home. She is supported in the day to day running of the home by two senior carers. The manager advised that she is allocated two days per week to complete specific management tasks. However during these periods she attempts to dedicate time to assisting staff in the activities provided for the people living in the home. As a result she advised that she usually works extra hours to complete the management tasks. This is another indicator of Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 24 inadequate staffing levels being provided and undue stress placed upon the manager. It was clear that staff had a good rapport with the manager and was observed to be comfortable in her presence and whilst discussing what needs to be done. Regular staff meetings were being held; the minutes indicated that a wide range of relevant topics were being covered. These indicated that the health and safety and wellbeing of people living in the home were paramount. The home has an established quality assurance programme. Since the last inspection the means of obtaining the opinions of the people who reside in the home has changed. Staff no longer assist in this process; this is completed by the help of family and friends in order to gain an unbiased view of the services provided. The manager audits every room of the premises; this is verified by an audit carried out by the operations manager. An annual report is collated and where shortfalls are identified an action plan is developed including timescales to resolve the issues. This indicates that the home is constantly striving to make ongoing improvements for the benefit of the people who live there. A file containing Regulation 26 reports was reviewed. A senior person within the organisation should carry out monthly unannounced audits of the home and produce a written report that is given to the manager. This is to monitor the day to day management of the home and to suggest action needs to be taken where deficits are noted. The file contained reports dated May, June, July August and October 2007, but none since. A requirement was made at the last inspection regarding the same shortfall. The requirement will be carried forward on this occasion but if not met at the next key inspection action by us will be considered. Maintenance records of equipment and utilities were reviewed; they confirmed that appropriate health and safety measures were in place to protect people from unnecessary accidents and injuries. Accidents were being recorded and any resultant action required was being carried out. Fire prevention processes were in place, which indicates that staff would respond appropriately in the event of an emergency. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 2 12 3 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 2 X X 3 x Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5 (1) (b) Requirement The service user guide must include the current fee rate, details about contributions by other agencies and information about the services that are not included in the fee rate. This is necessary to enable prospective residents and their representatives to make an informed decision about living in the home. People living in the home must be offered meaningful recreations to meet their preferences and aspirations. This is necessary to promote people to experience a quality lifestyle. Review the staff complement and ensure that sufficient numbers of staff are available to support service users in accordance with their assessed needs. N.B. Timescale of 30/04/07 has not been met. However as a result of this inspection we have Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 27 Timescale for action 31/05/08 2. YA11 16(2)(m) 31/03/08 3. YA33 18(1)(a) 15/03/08 4. YA39 2624 (2) been advised of action being carried out to comply. The home must sustain the action taken to prevent enforcement being taken by us. The Registered Provider must 30/04/08 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. N.B. Timescale of 30/04/07 has not been met therefore carried forward and must be treated as a matter of prioity. 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 YA22 Good Practice Recommendations It is suggested that the written complaints procedure be produced in an easy read format to assist people in understanding the content of the document. Worlds End Road, 58 DS0000016931.V356527.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V356527.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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