Inspection on 20/06/05 for 75 Ludford Road

This inspection was carried out on 20th June 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 but made no statutory requirements on the home.

Other inspections for this house

75 Ludford Road 25/11/08

75 Ludford Road 10/01/07

75 Ludford Road 07/03/06

75 Ludford Road 07/12/04

75 Ludford Road 22/06/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE Ludford Road, 75 75 Ludford Road Bartley Green Birmingham B32 3PQ Lead Inspector Sean Devine Announced 20 June 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 Older People. 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. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ludford Road, 75 Address 75 Ludford Road Bartley Green Birmingham B32 3PQ 0121 683 8855 0121 683 8855 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) Mind in Birmingham Roger Silvester Care Home 9 Category(ies) of Mental Disorder registration, with number of places Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate up to eight service users who are in need of care for reasons of mental health problems. 2. That the home can care for one named service user (aged 51) in need of care for reasons of mental health problems.. Date of last inspection 7 December 2004 Brief Description of the Service: 75 Ludford Road is a home that provides care and support for 9 people with mental health issues who are aged 55 years or over, the unit is managed by MIND and the accommodation owned by Focus Housing who take responsibility for the maintenance and upkeep of the building. The accommodation provided consists of seven single bedrooms and one double. The home in the main is decorated to a high standard. The communal space consists of two lounges, one smoking and one non-smoking, there is a dining area in the smoking lounge, and there is also a large kitchen. The rear garden is very pleasant, having a sheltered seating area, lawn and bedding plants. Within a close distance to the home there are a range of community facilities including, shops, pubs, churches, leisure facilities and a medical centre. The immediate area has a good public transport system. The home currently has nine service users in residency. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected on an announced basis by one regulation inspector over a period of one day. The inspector had opportunity to meet and talk with all residents at the home. Staff were interviewed on an informal basis, a tour of the building was undertaken and records pertaining to care provision and health and safety were viewed. A pre-inspection questionnaire had been completed prior to the inspection. Four residents had completed comments cards and returned them to the inspector prior to the inspection. The views and opinions of these residents in respect of the service they receive were positive. What the service does well: What has improved since the last inspection? An ongoing programme to train staff to have an awareness of what constitutes abuse and what to do about it has been implemented. Weekly menus after consultation with the residents offering alternatives are now available. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 6 Bathing, showering and washing facilities have been audited, the home is awaiting a report and this will give guidance as to how the changing needs of residents can met. The home has introduced a thorough medicines policy that reflects current practices and ensures that residents are supported to have their medicines managed and administered safely. The homes statement of purpose has been updated to include shortfalls in furniture and fittings in residents’ rooms and includes details that alternative arrangements will be made. The home has in place systems to assess the quality of services provided to residents and involves residents, their relatives and commissioners in this assessment. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5 and 6 Residents are aware of the facilities and services available prior to admission, the home gathers information prior to admission, which enables them to make a decision on whether they can meet the needs of the prospective resident. EVIDENCE: Residents files were sampled, pre-admission information including social work reports and care plans and also Care Programming Approach summaries, care plans and reviews were available. These documents identified the needs of residents. The home assists the residents to maintain contact with local mental health services and also specifically trains the staff team to have the necessary skills to support the mental health needs of residents. Residents’ files did contain some information about pre-admission visits by the residents to the home, however much of this information has now been archived as residents have lived at the home for a long period of time. The home does not provide an intermediate care service. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. The home does not adequately plan the care of residents; staff are not informed in written care plans on how to meet the needs of residents. All risks are not adequately assessed to ensure the safety of residents in respect of their health and well-being. EVIDENCE: Residents’ files contained essential life plans and daily routines, plans that adequately detail the needs of residents and inform staff in how to meet the needs of residents are not available. Inadequate written care plans have remained a concern for the last three inspections. Risk assessments identifying manual handling, nutrition and tissue viability needs of residents are not available. One resident has had an assessment by the continence promotion nurse; a record of the assessment and a subsequent written care plan were not available. The home ensures the monthly weights of residents are measured and recorded. Visits by and to the GP, CPN and hospitals are well recorded. Some residents confirmed they are able to see the optician, dentist and chiropodist when needed, records confirming visits were not seen by the inspector. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 10 The management of medicines on behalf of the residents is deemed to be generally safe; the practice is underpinned by a rigorous policy. The home must ensure that when as required medicines are prescribed a protocol of drug administration is developed and that any resident who self-administers medicines has a risk assessment completed. At present the residents can manage their own personal care needs with minimal physical support from staff, staff are skilled in motivating and encouraging residents to maintain these skills. All residents’ rooms and communal bathrooms and showers have suitable locks. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 The daily life and social activity needs, both individually and collectively, of the residents are clearly met by the home, enabling residents to enjoy their life at the home. EVIDENCE: Residents are content with the lifestyle at the home, they confirmed that they could plan their own day, including social events, meals and visits to and by their respected families. Residents confirmed that holidays are planned abroad and in England for later in the year. At the time of inspection residents confirmed that their favourite pastime was knitting and sewing. One resident confirmed that when feeling well, visits to the church are supported by the home. Residents on the day of inspection went shopping for personal items and also for food items, they were able to access public transport, one resident indicated this was the best part of the day. Residents confirmed that once a week they have a meeting about meals and plan the menu between them for the week ahead. The menu plans were seen to be healthy and nutritious. Food items are managed safely and in accordance with the Food Safety Act 1990. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home does have the necessary approach to protecting residents from harm, the home is also supportive to residents and their representatives should they need to raise concerns. EVIDENCE: The home has a complaints log, no complaints have been recently recorded at the home. The home has a complaints policy. The complaints policy is advertised on entry to the home. No complaints have been received at the commission. As identified at previous inspections the adult protection procedure must be amended to state that the gathering of information will only commence following an adult protection referral and subsequent directive from the adult protection team, other than the gathering of essential information from victim or witness. The manager and staff team do receive ongoing training to protect vulnerable adults from the risks of abuse. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26. The residents’ accommodation individually and collectively is well maintained to meet their ongoing needs and to provide a safe and comfortable environment. EVIDENCE: The home is well maintained, the MIND organisation does not maintain the building this is completed as needed by the landlord. The home has a rear garden with patio areas and a fixed gazebo, it is lawned in part and is safe for residents to use. There are two lounges, one with a dining area that provides further communal accommodation. All furniture and fittings in communal areas is domestic in style with a range to meet the collective and individual needs of residents. Toilets, showers and bathrooms are within very close proximity of residents’ rooms. There are two floor draining showers with a range of adaptive supports such as shower seats and grab rails. There is one bathroom sited upstairs. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 14 There are seven single rooms and one shared room, all provide residents with adequate space, the range of furniture and fittings in residents’ rooms is described in the statement of purpose. Although the home does not have all the required furnishings in all residents rooms, as described in the statement of purpose these are available if requested. The carpet in one residents’ room has “bobbled up” in places and needs to be made safe. All services including water, heating and lighting are available where needed and well maintained. Infection control measures are safe, the home has a laundry that has a sluice cycle on the washing machine and colour coded cleaning equipment and products. The home must ensure that the soap tablets in the upstairs communal bathroom toilet are removed to improve infection control. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Staff are mainly recruited and supported to a standard that promotes the overall protection of resident’s, further staff training is needed to ensure all staff have the necessary skills to meet the needs of residents. EVIDENCE: Staff rosters included with the pre-inspection questionnaire identified two staff on duty between 8am and 10 pm; the manager is normally additional to these numbers. At night one care officer is always on sleep duty at the home, no waking night staff are on duty. The pre-inspection questionnaire identified three care staff have an NVQ award at level 2 or above, this is approximately 40 of the care staff. Recruitment of new staff was in line with legislation and good practice, application forms are completed, a minimum of two references taken up, criminal records bureau disclosure gathered and health screening undertaken. Staff training in safe working practices was found to vary, the manager confirmed that staff friendly policies did not always encourage some staff to train. One staff member who has current COSHH training needs to update on Manual Handling and Health and Safety, further training is needed in Basic Food Hygiene and Protecting Vulnerable Adults from Abuse. One other staff member did not have current fire safety training. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35,36 and 38. The home is effectively and safely managed in the best interests of residents. EVIDENCE: The organisation has developed quality projects, which involves residents, staff and relatives. Other initiatives have included Quality Review Outcomes with Social Care and Health and Primary Care Trusts. The home also requests that residents complete an annual questionnaire. Action plans to improve and maintain performances are developed. The majority of residents have the ability to manage their own money and have either post office or bank accounts. One resident has money paid weekly, this is provided by the home, it is accounted for with receipts and witness signatures. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 17 Staff supervision is undertaken, the majority of staff receive supervision on a regular basis. The supervision records for one member of staff were not available. Supervision includes review of the previous month, areas for concern such as key-worker roles and action plans. The home has in place thorough risk assessments pertaining to fire, premises, staff and food. The fire risk assessment must be reviewed and include details of findings and compliance. The service, testing and maintenance of equipment and utilities are good, for example fire systems, gas, electric and water are regularly maintained. The manager does keep a record of all accidents on a format that complies with the Data Protection Act 1998, however the commission have not been informed of all such incidents that have affected the residents well being. Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 2 x 2 Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 19 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 OP7 Regulation 15(1)(2) Requirement Essential Life Planning documents must contain specific actions the home and staff take in order to meet the assessed needs of residents. This must include regularly recorded reviews. Previous timescale of 1/11/04 not met, this requirement is carried forward. A written plan of care for any resident in receipt of continence management products must be completed. The home must ensure that risk assessments for residents identify strategies for the minimisation of risk and be appropriately completed. Previous timescale of 1/10/04 not met, this requirement is carried forward. This must include full risk assessments in respect of tissue viability, manual handling and nutrition. All as required medicnes must Timescale for action 31/8/05 2. OP8 13(4) 31/08/05 3. OP9 13(2) 31/8/05 Page 20 Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 have an administration protocol in place to guide staff and residents. Any resident who self administers medicines, including inhalers must have a selfadministration risk assessment completed and regularly recorded compliance checks made by staff. All staff who handle medicines must complete an accredited course in the safe handling of medicines. Previous timescale of 1/10/04 not met, this requirement has been carried forward. The adult protection procedure must be amended to state that the gathering of information will only commence following an adult protection referral and subsequent directive from the adult protection team. This does not include gathering of initial information from victim or witness. 5/7/05 4. OP18 13(6) 31/10/05 5. OP24 13(4)(c ) 6. OP26 13(3) 7. OP28 18(1)(c )(i) Previous timescale of 1/10/04 not met, this requirement is carried forward. The manager must ensure that 31/8/05 that the flooring including carpets in residents rooms is safe, where carpet is bobbled it must be repaired or replaced. Effective infection control 31/8/05 measures must be in place in all communal toilet areas, tablet soap belonging to residents must be returned to their rooms after use. The manager must ensure that a 31/12/05 minimum ratio of 50 of care staff have achieved the NVQ Version 1.30 Page 21 Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc level 2 award. Previously a recommendation and is now carried forward as a requirement. All staff must receive induction / mandatory training as identified in the TOPSS programme and as listed in Standard 30.2 of the National Minimum Standards. Previous timescale of 30/6/05 not met, this requirement is carried forward. Records of all staff supervision must be available at the home. The fire risk assessment must be reviewed and include details of findings and compliance. The commission must be informed of incidents that have affected the residents well being. 8. OP30 18(1)(c )(i) 30/9/05 9. 10. 11. OP36 OP38 OP38 18(2) 23(4) 37(1)(2) 31/8/05 31/8/05 31/7/05 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 Good Practice Recommendations Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 Ludford Road, 75 E54 S16868 75 Ludford Road V225814 200605 Stage 4.doc Version 1.30 Page 23 - 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. 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