Inspection on 23/08/06 for 60 Raddlebarn Road

This inspection was carried out on 23rd August 2006.

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

Other inspections for this house

60 Raddlebarn Road 31/07/07

60 Raddlebarn Road 14/03/06

60 Raddlebarn Road 25/08/05

60 Raddlebarn Road 19/03/05

60 Raddlebarn Road 05/08/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 60 Raddlebarn Road Selly Oak Birmingham West Midlands B29 6HA Lead Inspector Kerry Coulter Unannounced Inspection 23rd August 2006 09:30 60 Raddlebarn Road DS0000054310.V309046.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 60 Raddlebarn Road DS0000054310.V309046.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. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 60 Raddlebarn Road Address Selly Oak Birmingham West Midlands B29 6HA 0121 258 3906 F/P 0121 258 3906 patrichardson@bvt.org.uk 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) Bournville Village Trust Mrs Patricia Susan Richardson Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Ms Richardson has at least 21 hours per week in a supernumery capacity, that is designated management time, not one of the roistered staff providing hands on care. 14th March 2006 Date of last inspection Brief Description of the Service: This home was formerly part of a core and cluster registration, but the owners applied to split the registration, and now 60 Raddlebarn Road has its own registered manager and staff team. At 60 Raddlebarn Road there are four places for people who have learning/sensory disabilities and who may also display behaviour, which challenges current service provision. The home has four single bedrooms, and a large staff office/sleep in room. The ground floor has one of the four bedrooms, large kitchen/dining room, and a separate lounge. To the rear of the home is a large garden. The home is situated close to shops and local amenities. Visitors to the home can request to see a copy of CSCI reports from staff as reports are located in the home’s office. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, reports from the provider and a pre inspection questionnaire. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. Due to their communication needs service users were not able to comment on their views of the home. Therefore to what it is like for service users to live at the home for service users time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: The home had a relaxed atmosphere. More than 80 of the staff have achieved the standard of having an NVQ in care. Training records show that staff receive regular training. It is a strength of this home that service users are supported by staff who know them well. The staff were very friendly. Observations revealed positive relationships between staff and service users. The staff were very happy to answer the questions from the Inspector. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. There are good supervision and support systems in place for staff. The Manager is making clear efforts to develop the service for the benefit of the people living there. The systems for the safe storage, handling and administration of medication were generally well managed. The standard of the environment is good providing service users with an attractive and homely place to live and meeting their needs. Service users bedrooms are well decorated and reflect their individual tastes, interests and personalities. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Individual plans need further development regarding goal setting so that these can be measured in the future. In line with ‘Valuing People’ health action plans need to be completed for each service user. Recruitment records for staff must be in the home so it is clear that the necessary checks have been done to ensure that staff are suitable to work with the service users. The quality assurance system requires development to make sure that service users views help to develop a plan for the home on how to move forward, thereby improving the overall quality of life for service users who live there. Arrangements must be in place so that service users who want to go on holiday can have one. The arrangements for on-call advice in an emergency need to be reviewed to ensure staff have speedy access to on-call advice to support them in their role and ensure the safety of service users. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 7 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. 60 Raddlebarn Road DS0000054310.V309046.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 60 Raddlebarn Road DS0000054310.V309046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to admission to ensure that their needs can be met by the home. EVIDENCE: The home was observed to have a satisfactory statement of purpose and service user guide in place. Each service user has their own copy of the guide. There have been no new admissions to the home for some years and so this made it difficult to fully assess practice. The admissions procedure was sampled and was observed to be satisfactory. However procedures sampled and discussion with the Manager indicate that assessments would be completed prior to a new service user being admitted to the home, followed by an initial review after four weeks, with a final review three months after admission to ensure that the service user had settled into the home. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 10 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 and 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Development of the care planning system is still in progress to ensure all staff are provided with all the information they need to satisfactorily meet service user needs. Arrangements are satisfactory to ensure that service users are supported to take risks within a risk assessment framework. EVIDENCE: Two service user care plans were sampled. The home has a service user plan for each individual, which includes detailed profiles, activity plans, and daily recording. In addition, some service users have individual support strategies and guidelines, in some cases devised by professionals working in partnership with staff in the home. Lots of work is in process to develop the care plans to make them more service user focused and individualised. There is still quite a lot of work to do to complete the plans but steady progress has been made since the last inspection to include the usual routines and likes and dislikes of service users in the plan. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 11 Plans sampled had been recently reviewed but did not always provide staff with step – by - step details of the support that the individual needed so that they can be supported consistently by all staff. All staff spoken with undoubtedly had very good knowledge of the needs of the service users but the good knowledge they had did not always transfer into the care plan. A review meeting had taken place for one individual where some actions had been agreed. Unfortunately no target dates for the actions had been set and the care plan did not track progress made towards the agreed actions. It was identified at the last inspection that further information about individual communication needs were needed in their care plan. Since then staff have been working with the Speech and Language Therapist. One service user now has their own ‘Communication Passport’ which specifically details their communication needs. The Manager said that it is intended to develop communication passports for the other service users. Members of staff were observed encouraging service users to make choices about day-to-day matters, such as what to drink and what they wanted to do on that day. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. There is evidence that service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. Risk assessments were noted to be in place for the home and service user activities. The Manager has cross referenced risk assessments with care plans so that the reader is directed from one document to the other. It is recommended that the review of the assessment includes more evidence of the evaluation process to evidence that full consideration has been given to the control measures in place. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. EVIDENCE: Since the last inspection the staff have been working on the planning and assessment of activities to ensure that individual service users are offered activities that they enjoy. Activity plans for individuals have been reviewed and a review of each activity undertaken is being done to evaluate if the activity was suitable for the individual. Records and discussions with staff evidence that activities on offer include walks, shopping, aromatherapy, going to the pub, going out for meals, tactile sessions and day trips. Some service users have recently been to the Black Country Museum and to the theatre to see Chitty Chitty Bang Bang. It is a good development for one service user that he has started to go to a day centre once a week, with the support of a member of staff. Staff said that he was enjoying going. All service users were out at activities on the morning of the inspection visit. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 13 Discussion with staff indicates that service users have not been on a holiday this year due to difficulties with staff payments for the holiday. The Manager confirmed this was the case and said the Bourneville Village Trust were reviewing its policy for payments to staff. Most service users do not have regular contact relatives. Discussion with the Manager indicates that staff try and maintain contacting by supporting service users to send cards at birthdays and Christmas. Service users also have some contact with people who live in nearby care homes, owned by the Bourneville Village Trust and see friends at day centres. It was recommended at the last inspection that work should be undertaken to increase the social circle of service users. The Manager said that the home was attempting to do this and were using methods such as taking service users to a local pub where they were becoming regulars and mixing with local people. The Manager said that she was also looking at how volunteers could be utilised in the home. There was no evidence of strict house rules. Staff were observed sitting and socialising with service users. Service users are able to choose whether or not to spend time with others, or to have private time in their own rooms. Where restrictions are in place these were seen to be as a result of a risk assessment and included in the care plan. The home has an eight week rotating menu, these show that a varied and nutritious diet is on offer that includes the daily recommended five portions of fruit and vegetables. Food records sampled showed that choice is available as service users did not always eat the same meals. Food stocks were seen to be sufficient with most foods being quality brands. A member of staff was observed preparing the evening meal, the food being cooked matched the menu for the day and looked fresh and appetising. Staff spoken with said that service users were encouraged to choose meals, one gave an example of how one service user gets his own breakfast cereal from the cupboard. They said this individual had not been able to do this for himself when he first moved to the home but with encouragement from staff he had developed the skills to be able to do this independently. 60 Raddlebarn Road DS0000054310.V309046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of service users are generally met with evidence of good multi-disciplinary working taking place on a regular basis, progress towards completing health action plans is evident. The systems for the administration of medication are good and ensure service users receive the medication they need. EVIDENCE: Service users records included detailed manual handling risk assessments. These stated how the service users were to be supported by staff with their mobility and how the risks to service users and staff are to be minimised when doing this. Service users were well dressed and their clothes were appropriate to their age, gender, culture, the weather and the activities that they were doing. Records sampled show that service users are supported by staff to go to the barbers and also to buy their own toiletries. It is good that for one service user a personal routine for bathing has been produced with help for the Speech and Language Therapist, this provides clear instructions for staff so that the individual is supported in a consistent manner. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 15 It has been identified at previous inspections that service users do not have individual health action plans. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. However, in conjunction with the Community Nurse a one page health summary has been completed for each service user. This includes pictures to make the format more accessible for service users. The Manager said that she was attending a managers meeting in September where a decision would be made on the new format to be used for health action plans. A sample inspection of service users’ health records indicates that service users are receiving routine access to general health services, such as the dentist and optician. Records are also maintained of regular weight monitoring. Guidance was available for staff on individual health care issues such as diabetes, epilepsy and the use of food thickeners. The systems for the safe storage, handling and administration of medication were well managed. The home utilises a monitored dose system for medication. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. One service user is prescribed Midazolam used to treat epilepsy. The Community Nurse has trained staff in the administration of this. A protocol was in place that had been agreed by a multi- disciplinary team. Most staff at the home have received accredited medication training, those who have not are currently undertaking this training. It is good practice that the Manager periodically observes staff administering medication. 60 Raddlebarn Road DS0000054310.V309046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure. Adult protection systems need to improve to ensure service users are being protected from abuse and their welfare promoted. EVIDENCE: The CSCI has not received any concerns or complaints about this home since the last inspection. The home has a satisfactory complaints procedure in place. Staff at the home have received prevention of abuse training to ensure they are aware of the possible signs of abuse and action needed to safeguard the service user. The arrangements for the safe keeping of service users personal monies was sampled. These were satisfactory. Receipts were available for all expenditure. Inventories are available to show the personal belongings of each service user. As recommended at the last inspection the format has been improved so that staff are better able to track when new items are purchased and old items discarded. Records sampled show that confirmation that a Criminal Records Bureau check has been done for agency staff is always sought before they work in the home to ensure that unsuitable individuals are not working with the service users. Unfortunately the recruitment records for permanent staff who work in the 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 17 home did not always show that a robust procedure had been followed, this is further detailed in standard 34. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 18 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, 28 and 30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing service users with an attractive and homely place to live and meeting their needs. EVIDENCE: Generally the home is decorated and maintained to a satisfactory standard. Furnishings, fittings, adaptations and equipment are as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose. The home was maintained at a comfortable temperature. Several fans were located around the home, the Manager said that additional fans had been purchased during the heat wave to ensure the home did not become too hot. The home has a lounge and large kitchen/dining area. To the rear of the home is a large garden and off road parking. A sleep-in room is provided for staff that sleep-in at the home. Service users bedrooms contained many appropriate personal effects and equipment. Bedrooms were observed to be personalised according to individual needs, culture, gender and preferences. One service user has new pictures and lampshades in his room, the Manager said that the individual had been assisted in choosing them himself. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 19 The Manager said that quotes have been obtained to repaint the hallway and fit new carpets, it is hoped this work will be done soon, making the home a nicer place to live. Redecoration of the kitchen and diner is also scheduled for September. As at the last inspection, several wheelchairs were being stored in the laundry, making this room a little cluttered. The Manager said that funds had now been agreed for a shed in the garden that could be used for storage purposes. The home was observed to be clean with no unpleasant odours. Appropriate hand washing facilities were available in bathrooms and the laundry. A member of staff was observed preparing the evening meal, the staff wore protective clothing and used the appropriate coloured chopping boards to ensure the risk of food poisoning was reduced. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 20 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 and 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development was good but records need to evidence the recruitment procedure is robust and protects service users. EVIDENCE: It was noted that both staff and tenants appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and generally treat people respectfully. The pre inspection questionnaire completed by the Manager indicates that 83 of staff have completed an NVQ in care, this contributes towards service users being supported by competent and qualified staff. This exceeds this standard that 50 of care staff must have NVQ level 2 or above. Sampling of the staff rota and discussion with staff indicates that sufficient numbers of staff are on duty to meet service users needs. There are generally three staff on duty during the day. At night there is one waking night staff and one member of staff sleeping –in. The Manager does work some ‘hands on’ shifts but usually has three days per week designated for management and administrative tasks. The home does not have any staff vacancies and it is a 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 21 strength of this home that service users are supported by staff who know them well. The recruitment records for three members of staff were sampled. Evidence of satisfactory criminal record bureau checks being undertaken was available for all three. However the records did not contain two written references for two staff. The Manager said that these were kept at headquarters. Following a telephone call to headquarters the Manager was able to obtain a copy of the missing references for one member of staff but for the other staff these had not been located by the end of the visit. Copies of the references need to be available in the home to evidence that a robust recruitment procedure is followed for the protection of service users. Training records show that staff receive regular training to include adult protection, physical intervention, manual handling, food hygiene, diabetes, confidentiality and equality and diversity. Some staff have recently attended nutrition training which they said had been useful when planning menus. One staff spoken with said they had recently undertaken refresher training in first aid and manual handling and had also done some in-house training on Makaton (sign language). They said that they thought the standard of training had been good and it had all been relevant to their role. Induction arrangements were not sampled as no new staff had started work in the home since the last inspection, however satisfactory induction arrangements were seen to be in place for agency staff. There are good supervision and support systems in place for staff who receive regular formal supervision. Staff meetings take place regularly, usually on a monthly basis. Staff spoken with said they were satisfied with the levels of support and supervision on offer. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 22 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, 39 and 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed. Adequate arrangements are not in place to ensure that service users or their representatives views underpin all self-monitoring, review and development by the home. Health and safety of staff and service users was generally well managed. EVIDENCE: The style of management in the Manager is making clear efforts people living there. The Manager and has achieved the Registered care qualification. home is relaxed, open and inclusive, and the to develop the service for the benefit of the has a significant amount of experience in care Manager’s Award as well as having an NVQ 4 At the previous inspection visit there was evidence of the statutory reports being completed by the representative of the organisation on a monthly basis to evidence they are overseeing the running of the home and ensuring the 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 23 health and welfare of the service users. At this visits reports were available but they were not always on a monthly basis. The Manager said that this was due to a change in personnel at Bourneville Village Trust (BVT). Following the visit a letter was received from BVT’s new Director of Supported Housing stating that a programme of visits had now been planned. The home has previously not had a full quality assurance system in place that takes into account the views of service users and their representatives. However discussion with the Manager and the Director of Supported Housing indicates that a quality management system has been purchased and that Managers had received training in its effective use from a training consultancy. It is hoped that work to implement the system will commence in October. Health and safety at the home was well managed. Monthly health and safety audits are completed. An examination of the home’s fire safety records indicate that routine testing of alarms and lights is being carried out at the appropriate frequencies. The records also show that fire drills are being routinely carried out. Staff were overdue their six monthly fire training. This was brought to the attention of the Manager who ensured that the staff on duty undertook refresher fire training by watching a fire video. It was also put in the homes diary by the Manager for other staff to watch the video when on duty. A Corgi registered engineer has tested the gas equipment and stated that it was in a satisfactory condition. The hot water monitoring log confirmed that water temperatures are checked weekly and that water is maintained at a safe temperature. Current certificates of registration and employers liability insurance were on display. The procedures for on call assistance for staff in the event of an emergency were discussed with the Manager. The procedure within this home differed to the other BVT homes in that staff have to call a central emergency control unit. This unit covers a wide range of BVT services, not just care homes and so would not always be staffed by someone who would have a satisfactory level of knowledge about the needs of service users who have a learning disability. The Manager said that the control centre staff usually have to contact other Managers for advice who may not actually be on call. This system has the potential to delay the appropriate advice being given to the staff in an emergency and the arrangements should be reviewed. 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 24 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12(1)15 Requirement Care plans: Set targets with measurable outcomes. Further consideration must be given to how service users are involved in the development of the plan to include their goals and aspirations. Outstanding from 30/11/05. Timescale for action 30/11/06 2. 3. YA14 YA19 Ensure the plan details the specific support needs of service users. 16 (2) (m, Arrangements must be in place n) so that service users who want to go on holiday can have one. 12(1) In line with Valuing People a health action plan should be developed for each service user. This is a personal plan about what a person with learning disabilities can do to be healthy. It lists any help people might need to do these things. Outstanding from 30/12/05 but work in progress. 30/12/06 30/12/06 60 Raddlebarn Road DS0000054310.V309046.R01.S.doc Version 5.2 Page 26 4. YA23 YA34 13(6) 19 5. YA39 12(1)14 6. YA39 26 7. YA42 13(4) 23 12(1)(a) 8. YA42 Ensure that two satisfactory written references are obtained for all staff before they commence work, a copy must be retained in the home for inspection. A formal quality assurance system must be in place that seeks the views of service users and their representatives. Outstanding from 30/05/06 but work in progress. Ensure visits to the home by the representative of Bourneville Village Trust occur on a monthly basis with a report available. Ensure all staff receive fire refresher training every six months. ( Part addressed during visit) Review the arrangements for oncall to ensure staff have speedy access to on-call advice from an individual who has the necessary skills and knowledge regarding learning disability and care standard regulations. 30/10/06 30/10/06 30/10/06 30/10/06 30/11/06 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 YA9 Good Practice Recommendations Risk assessments-It is recommended that the review of the assessment includes more evidence of the evaluation process to evidence that full consideration has been given to the control measures in place. Consideration should be given to increasing the storage facilities for equipment such as wheelchairs. Previous requirement. 2. YA24 60 Raddlebarn Road DS0000054310.V309046.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: 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. Extracts may not be used or reproduced without the express permission of CSCI 60 Raddlebarn Road DS0000054310.V309046.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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