Inspection on 18/05/05 for 71 Coriander Close

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

71 Coriander Close 02/12/08

71 Coriander Close 28/12/06

71 Coriander Close 03/02/05

71 Coriander Close 11/01/05

71 Coriander Close 14/09/04

71 Coriander Close 09/03/04

71 Coriander Close 18/09/03

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 08/07/2008.

CARE HOME ADULTS 18-65 Coriander Close 71 Coriander Close Northfield Birmingham B45 0PB Lead Inspector Brian Reamsbottom Unannounced 18th May 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. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Coriander Close Address 71 Coriander Close, Northfield, Birmingham B45 0PB 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) 0121 460 1846 0121 457 8355 Sense West Amanda Wilson (Acting Manager) Care Home 3 Category(ies) of Sensory Impairment & Learning Disability (3) registration, with number of places Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents Must Be Aged Under 65 Years Date of last inspection 3rd February 2005 Brief Description of the Service: 71 Coriander CLose is a three bed roomed terraced house, situated in the middle of a housing estate in Northfield, Birmingham. It is registered for three people with learning disabilities and sensory impairment. Trident Housing owns the premises, and Sense in the Midlands are the care providers. The home consists of a downstairs toilet, kitchen with combined area for dining, lounge and sensory room. The laundry facilities are housed within the klitchen area. On the first floor there are three service user bedrooms, a bathroom and toilet and a small staff office. To the front of the house there is off road parking. There is a garden to the rear of the house. The home is not accessible to people who may use a wheelchair as there is no lift to access the first floor or aids and adaptations to assist people with impaired mobility. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours. The inspector met three service users and two members of staff. There was no communication with service users due to their complex needs. During the inspection the inspector sampled the following records: Care plans, risk assessments, fire, health and safety, complaints and adult protection procedures, daily diaries and medication sheets. What the service does well: What has improved since the last inspection? What they could do better: Where records ask for specific details these must be more accurately maintained, for example, in the daily diaries the boxes provided to record food are not always recorded. Service users should be given the opportunity to experience the challenge of a wider range of leisure activities. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 6 The organisation needs to keep staff fully informed of what training is available to enable them increase their knowledge and skills. The organisation needs to do better to responding to requirements made by CSCI to ensure the care provided meets individual needs. 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. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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 Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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) 1,2,4,and 5 Information is available to enable prospective users make an informed choice as to whether they want to live at the home. Some further development is required to fully meet the standard. EVIDENCE: Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 9 There have been no new admissions to the home recently, however, care plans sampled included individual needs assessments. There was no evidence that a trial period of three months is offered to prospective service users, followed by a review. An action plan was seen showing that a request has been made by the home to have trial periods included in the documentation, has been sent to senior management. At the last inspection there was a requirement that service user contracts/terms and conditions needed further information. The service user’s history files evidenced that progress is being made in adding the additional information. Requirements for this information have been made at previous inspections. The timescales set at the last inspection have now lapsed and must be addressed as a priority. It was stated that the Service User Guide is now available in pictorial form, however, this was not evidenced at this visit. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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 standard(s) 6,9 and 10 The system of care planning and risk assessment is adequate and ensures that appropriate guidance is available to staff to enable them meet individual needs. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 11 EVIDENCE: The care plans sampled evidenced that service users needs are reviewed on a regular basis. The ‘core’ meetings held each month review the needs and goals of each service user. The input to these meetings by service users is very limited due to their complex needs. However, on reading the care plans and in observing the interaction of the staff group with service users, it is clear, that the staff are knowledgeable as to the needs of service users. The risk assessments are in the process of being further developed. These were evidence in the service user’s care plans. The sampled risk assessments show clearly that they have been reviewed, with an evaluation as to why the risk is still relevant. There was detailed evidence in the support required by service users . On speaking with members of staff it was clear that they participate in the review of care plans. There was evidence that the staff team sign to state that they agree with the assessments. All confidential information pertaining to service users was seen to be securely held in the office. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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 standard(s) 17 13, 14,15 and The homes system for recording the diet and fluids provided to service users does not adequately indicate that they receive a varied and nutritious diet. Service users are supported to undertake a range of activities. No systems of evaluation were available to demonstrate how they assessed the appropriateness of these activities. EVIDENCE: Service users are very much part of the local community, they access the local cinema, tenpin bowling and pub. There are frequent recordings in the daily diaries that service users enjoy the pub for meals out. Service users take part in swimming and horse riding sessions. These activities are historical to the organisation. It is difficult to ascertain if the service users enjoy these activities. It would be good practice to give service users the opportunity to experience other activities. Use is made of a soft toy room away from the home. Two service users are going to Blackpool for the day the third Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 13 service user is having a quiet day with a member of staff, as she does not wish to go. Service users are encouraged to maintain links with family and friends. A service user has good contact with her mother with the assistance of staff as required. Care plans include a list of likes and dislikes of items of food of service users. These lists should be reviewed on a more regular basis, reflecting their changing needs. It would be good practice to introduce a greater variety and choice of foods. A service user was observed asking for a hot drink. He came to the kitchen and with the help of a staff member made himself a cup of coffee. The service user appeared happy and relaxed in performing this task. The member of staff commented that this was good progress for the service user, as he was reluctant in the past to participate. It reflects the positive input of the staff team giving good guidance and support. The staff team record the food intake of each service users in daily diaries, on occasions these records are incomplete. Fluid intake is recorded more on an ad hoc basis and needs to improve. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20 Systems are in place to manage service users healthcare needs, ensuring they receive the healthcare they require. Medication management was generally well maintained, but improved safe storage facilities are required to ensure safety. EVIDENCE: Care plans indicated that service users receive the appropriate support to meet their needs. Observation and records indicated that personal care is done in privacy and in a gender sensitive manner, in the service users’ bedrooms. The service users were well presented. The female service users had their hair done, in particular one service user’s hair was done in a style to meet her cultural and ethnic needs. Care plans indicated that service user’s health needs are being met. There are records of visits to other professionals when required. Health Action Plans were discussed with staff members, they said that management were in the process of implementing them. However, the staff members were not too sure of the content that should be in the plans. This should be addressed at staff meetings. The medication for service users was appropriately stored. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 15 There is not a cabinet for the storage of Controlled Drugs. A cabinet must be purchased, it must have a double locking mechanism and fixed to an appropriate wall with rag bolts. Wooden cabinets do not conform to the Misuse of Drugs (Safe Custody) Regulations 1973. The majority of staff have had accredited training in medication. There is a record of specimen signatures and initials in place for staff members who administer medication. There are protocols in place for service users on ‘as required’ (PRN) medication. Copies of prescriptions are on file, unfortunately, not all prescriptions are copied. All prescriptions must be copied. Medication was administered as directed, the Medication Administration Records (MAR) confirmed this. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 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 standard(s) 22 and 23 The adult protection and complaints procedure protect service users from harm. Some further development of adult protection procedure is required to reflect the commitment to multi-agency working. EVIDENCE: There have been no complaints received by the home or the CSCI since the last inspection. A member of staff stated that the complaints procedure is now available in pictorial and audiotape formats to meet the needs of service users. The formats were not available for inspection purposes. The protection of vulnerable adults procedure does not reflect the spirit of the Birmingham’s Multi-Agency Guidelines. The staff group must be given clear guidelines to follow enabling them to protect the people living in the home. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 29 and 30 The home although restricted in space is decorated and furnished to meet service users needs. Systems for managing cross infection are not adequate, and potentially placing service users at risk. EVIDENCE: A tour of the home was not undertaken at this visit. The home is small with narrow corridors. Accommodation could not be offered to people with mobility restrictions. Wheelchair users would be unable to access the home. A member of staff said alternative accommodation is planned for in the future for all service users. However, the service users appeared content in their surrounding and were observed to move around the home with assistance from the staff. The home was decorated and furnished to a satisfactory standard. The lounge was comfortable and had a good well lived in feeling. Contractors are coming to replace the carpets on the ground floor. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 18 The home was clean, hygienic and free from offensive odours. The laundry facilities are situated in the kitchen/dining area unfortunately, there is no alternative space to available. This poses a risk of cross infection. There is no specialist equipment available for example, bathing adaptations as the present service users do not require any specialist equipment. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 36 Staff levels are adequate to meet the needs of service users. Staff receive the training required to meet service users needs. EVIDENCE: There is three staff on duty at each shift. Two service users have 1to1 staffing. This gives greater flexibility in meeting individual needs. There is one waking night staff with an on call person for support. On discussing training with staff members it is evident that the organisation is committed to training. All members of staff have done statutory training. The majority of the staff group have completed NVQ training to level 2 or 3. A member of staff is hoping to complete level 3 training by August 2005. The staff on duty were rather vague in their understanding about the Learning Disability Award Framework (LDAF) training. On observing interaction between staff and service users it was clear that the staff were using their knowledge and skills. The rapport was good adult to adult communication. A member of staff commented that with having a stable staff group the incidents of challenging behaviour have lessened. The members of staff reported that they have supervision sessions every month. The staff members feel well supported by management and at easy discussing their training and developmental needs. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 20 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) 39 and 42 Outcomes for service users with regards to their health and safety are being upheld by a well managed home. EVIDENCE: The organisation’s audit department undertakes a full audit of the service. A General Manager does the Regulation 26 visits these visits are unannounced. Service users do not have meetings due to their complex needs. The staff have developed good relationships with service users. The staff bring the changing needs of service users to the monthly ‘core’ meetings for discussion and decide what action must be taken to meet needs. There are policies and procedures in place that comply with current legislation. Risk assessments for the premises, fire and food are available. The risk assessments for service users are in the process of being reviewed and updated. The fire logbook is being accurately maintained all test and checks have been done and recorded. Records of fridge/freezer temperatures and water temperatures are tested and accurately recorded. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 21 The COSHH cupboard was observed to be kept locked when not in use. All mops and buckets are colour coded for the areas of use. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 22 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 2 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 3 Standard No 11 12 13 14 15 16 17 x x 3 x 3 x 2 Standard No 31 32 33 34 35 36 Score x x x x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coriander Close Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 23 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 YA 1 Regulation 5.(1) (c) (e) Requirement The home has produced a service user guide the following information must be added: Standard form of contract/terms and conditions. It must be in formats to meet the needs of service users. There must be a three month settling in period followed by a review with service users. service users contract must include details of the home and allocated room. Risk assessments require further development. Riask assessments must include more than just a date and signature. There must be an evaluation of the risk asessments. An appropriate medicine cabinet must be purchased for the safe storage of Controlled Drugs. Timescale for action 30 June 2005 2. 3. 4. YA4 YA 5 YA 9 1.(4)(i) (c)(8) 5.(i)(c) 7.(c) 13.(4)(c) 30 June 2005 30 June 2005 30 June 2005 5. YA 20 13.(2) 31 July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 24 Coriander Close 1. 2. Standard YA 17 YA 19 It would be good practice to record the fluid intake of service users to ensure that they are drinking enough to meet their health needs. Implement health action plans for service users. Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House, 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 Coriander Close E54_S17155_Coriander71_V227991_UI1806005 stage 4.doc Version 1.30 Page 26 - 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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