Inspection on 25/08/05 for 60 Raddlebarn Road

This inspection was carried out on 25th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

60 Raddlebarn Road 31/07/07

60 Raddlebarn Road 23/08/06

60 Raddlebarn Road 14/03/06

60 Raddlebarn Road 19/03/05

60 Raddlebarn Road 05/08/04

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Polesworth Group 32 Station Road

Aston Court Nursing Home

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

CARE HOME ADULTS 18-65 Raddlebarn Road, 60 60 Raddlebarn Road Selly Oak Birmingham B29 6HA Lead Inspector Kerry Coulter Unannounced 25 August 2005 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 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 Stationary 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. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Raddlebarn Road, 60 Address 60 Raddlebarn Road Selly Oak Birmingham B29 6HA 0121 258 3906 0121 258 3906 Telephone number Fax number Email 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 Younger people with learning disabilities and registration, with number physical disabilities. of places Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 March 2005 Brief Description of the Service: This home was formerly part of a ‘core and cluster’ registration, but last year the owners applied to split the registration, and now 60 Raddlebarn Road has it’s 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. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over three and a half hours. Conversations with some of the service users were limited due to their needs and limited verbal communication abilities. However, the Inspector met all four service users and time was spent observing care practices, interactions and support from staff. A tour of the building and garden was made. Service user care plans and risk assessments were inspected. A number of Health and Safety records were inspected. The Inspector had the opportunity to talk with the Manager and several care staff. During this visit the Inspector did not have opportunity to speak with relatives and other health professionals. What the service does well: What has improved since the last inspection? What they could do better: The provider needs to ensure that the service user guide is produced in a format that is more appropriate to the communication needs of the service users. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 6 Individual plans need further development regarding goal setting so that these can be measured in the future. Further thought needs to be given to how the service user is included in the care planning and goal setting process and how their participation is recorded on the plan. Where there are additional charges to service users the provider must ensure written and up to date agreements are in place detailing how the charges are worked out. 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. 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. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The format of the Service User Guide requires development to enable service users to be clear about the services the home provides to meet their needs. EVIDENCE: The home has a statement of purpose, this document was assessed as satisfactory at the inspection in March 2005. It is an outstanding requirement that the service users guide is produced in a format accessible to service users. Consideration should be given to the use of pictures, video or audio as suitable to individual need. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 People are supported to take responsible risks, written assessments need to be available for all identified risks and further work needs to be done on how this information is presented. 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. Staff are currently working with the Speech and Language Therapist regarding the communication needs of one service user. Plans sampled had been reviewed in the last six months. The plans recorded some short term and long term goal setting. Further thought needs to be given to how the service user is included in the care planning and goal setting process and how their participation is recorded on the plan. Where goals are set the plan needs to record how they will be achieved and include dates for evaluation. Two service users at the home have motability vehicles, contracts for these are available in the home. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 10 The other two service users contribute towards the cost of these vehicles. However up to date agreements for this were not available detailing how the cost is worked out and signed by the service user or their representative, ideally this should be someone external to Bournville Village Trust such as a relative or advocate. 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 commenced the process of cross referencing risk assessments with care plans and including details of the evaluation process when the assessment is reviewed. The home has two copies of service user risk assessments, initially it appeared as if risk assessments had not been reviewed six monthly but the second copy of the assessment was up to date. The Manager must ensure that any copies duplicate the original assessment but it is recommended that only one assessment is in use. One service user is at risk from eating cigarette ends. Discussion with the Manager indicates that measures are in place to reduce the risk of this occurring but no written risk assessment had been completed. Following the inspection the Manager completed a risk assessment and forwarded this to the CSCI. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 17 A range of activities is offered in order to promote personal development, participation in the life of the local community and enjoyable leisure time. Service users enjoy a healthy and nutritious diet and exercise choice about what they eat. EVIDENCE: Each service user has their own activity timetable. Service users have the opportunity to attend a local day centre. To improve the variety of activities on offer the Manager has recently obtained places for service users at art therapy at the local Mac Centre. Encouragement is provided for service users to take part in many aspects of daily living, such as domestic tasks and shopping for personal items. Records sampled and discussions with staff indicate that people who live at the home participate in activities such as aromatherapy, relaxaway, library visits, cinema and meals out. Service users have recently been on a day trip to Weston-Supemare and a holiday is booked for September. The home has an eight week rolling menu and keeps a record of the food provided to service users. The menu indicated that a varied and balanced diet is provided. The food cupboards, fridge and freezer were well stocked. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 The health needs of service users are generally met. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure service users receive the medication they need. The storage of controlled medication needs to improve. EVIDENCE: Records show that referrals are made to healthcare professionals as and when required. One service user is currently receiving input from the Speech and Language Therapist. Where service users have epilepsy their seizures are monitored and their medication is regularly reviewed at the epilepsy clinic. A sample inspection of service users’ health records indicates that service users are receiving routine access to general health services, such as dentist and optician. Records are also maintained of regular weight monitoring. 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. Discussions with the Manager indicate that she is planning to introduce health action plans with input from the Community Nurse. The systems for the safe storage, handling and administration of medication were generally well managed. The home utilises a monitored dose system for Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 13 medication. 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. As required at the last inspection protocols were available for the administration of ‘as required’ medication. One service user is prescribed a Schedule 3 controlled medication, this was observed to be stored in the medication cabinet. To comply with the Misuse of Drugs Act 1971 It must be stored in the home’s controlled medication cabinet. It is also good practice to record the stock held in the controlled medication register. Following this inspection the Manager contacted the CSCI and stated that the medication was now being stored correctly. Staff at the home receive accredited medication training and it is good practice that the Manager also periodically observes staff administering medication to ensure competence. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints procedure. Adult protection procedures show that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The complaints procedure was examined at the inspection in March 2005 and was found to be satisfactory, it included all the relevant and required information including the address and telephone number of the CSCI. The Manager stated that one informal complaint had been received from a neighbour in June regarding noise. Discussion with the Manager and observation of the complaint log indicates that the complaint was appropriately responded to. The last inspection identified that the Bournville Village Trust adult protection policy was a lengthy document and it was not clear as to the procedure to follow if an allegation of abuse is made or abuse is suspected. It was recommended that a procedure is developed that clearly states the steps staff should take to ensure the correct procedure is followed. This has now been done. The procedure is satisfactory but would benefit from the inclusion of contact telephone numbers of the local Vulnerable Adults Officer from the West Midlands Police, the emergency duty social work team and area office. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 27, 28 & 30 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: Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 16 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 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 were personalised and contained many appropriate personal effects and equipment. The home has a bathroom on the ground and first floors. One of the bathrooms has adapted bathing facilities. Staff told the inspector that the bathing facilities are suitable to the needs of the current service users. New garden furniture has recently been provided, this makes the garden a more pleasant area in which to sit and spend leisure time. An incident occurred in the home where a service user broke his bedroom window, the window was repaired. The Manager has ensured that the design of the window meets this individuals needs by arranging for a Perspex covering to be installed to prevent future breaking of the window. The flooring in the kitchen and in one bedroom is scheduled for replacement, the Manager stated that this was to be done when service users are on holiday, thereby causing little disruption to the daily routine of the service users. The lounge carpet is planned for replacement in 2006. Infection control procedures are satisfactory. The home was clean and free from offensive odours. The home has a laundry room with a sluice cycle washing machine. Lidded bins, liquid soap and paper towels are provided in bathrooms, the kitchen and laundry. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Current staffing arrangements meet the needs of the service users. EVIDENCE: Discussion with the Manager and observation of the rota indicates that 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. This appears to be satisfactory to meet the needs of the service users. At the last inspection in March the home had several staff vacancies, regular bank and agency staff were being used to cover the vacancies. The organisation had tried to recruit staff but have not been successful. Progress on staff recruitment has now been made, a new member of staff has commenced work in the home and the Manager is awaiting the outcome of a Criminal Records Bureau check for another potential new member of staff. The recruitment of additional permanent staff will contribute to service users having a stable and consistent team of staff to meet their needs. Discussion with the Manager and sampling of records evidence that the Manager arranges regular staff meetings. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Satisfactory systems are in place to ensure the health and safety of service users. EVIDENCE: Health and safety at the home was well managed. 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. Prior to the CSCI inspection the Fire Officer from West Midlands Fire Service visited the home and made several requirements. During the CSCI inspection the Fire Officer visited the home and stated he was satisfied with the progress made towards meeting the requirements. The COSHH cupboard was checked and found to be secure. The hot water monitoring log confirmed that water temperatures are checked weekly and a hand test carried out at this inspection confirmed that water was of a comfortable and safe temperature. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 19 A representative of Bournville Village Trust visits the home on a monthly basis. The report from the visit in July identified that grab rails were required at the top of the stairs to reduce risk to one service user. These were observed to have been fitted. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Raddlebarn Road, 60 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 21 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 1 Regulation 17(2) & Schedule 4(2) 12(1) & 15 Requirement The service user guide must be available in a suitable format for the service users. Outstanding from 13/11/04. Care plans: Set targets with measurable outcomes. Further consideration must be given to how service users are involved in the developemt of the plan to include their goals and aspirations. Up to date documented agreements must be in place to demonstrate how each individual contributes to vehicles costs. These must demonstrate that cost is equitable to use and provide value for money for the individual. These should be signed by the service user or their representative. A risk assessment needs to be completed for service user at risk of eating cigarette ends. Timescale for action 30/11/05 2. 6 30/11/05 3. 7 17(2) Schedule 4(9) 30/12/05 4. 9 13(4) 5. 19 12(1) In line with ‘Valuing People’ a health action plan should be developed for each service user. This is a personal plan about Risk assessmen t has been forwarded to the CSCI. 30/12/05 Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 22 6. 20 13(2) what a person with learning disabilities can do to be healthy. It lists any help people might need to do these things. Schedule 3 controlled 30/9/05 medication: To comply with the Misuse of Drugs Act 1971 it must be stored in the home’s controlled medication cabinet. 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. Refer to Standard 20 23 Good Practice Recommendations Receipt of and stock balances of Schedule 3 controlled medication should be recorded in the controlled medication register. The adult protection procedure would benefit from the inclusion of contact telephone numbers of the local Vulnerable Adults Officer from the West Midlands Police, the emergency duty social work team and area office. Raddlebarn Road, 60 E54 S54310 Raddlebarn Road 60 V246049 250805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham and Solihull Office 1st Floor, Ladywood House 45 - 46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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