CARE HOME ADULTS 18-65
Ludford Road, 75 Bartley Green Birmingham West Midlands B32 3PQ Lead Inspector
Sean Devine Unannounced Inspection 7th March 2006 08:50 Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 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 Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 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. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Ludford Road, 75 Address Bartley Green Birmingham West Midlands B32 3PQ 0121 683 8855 0121 683 8855 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) Mind in Birmingham Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Residents must be aged under 65. That the home can provide a service to 8 residents for the purpose of a Mental Disorder. 8 MD That a Registered Manager is in post by the 1st February 2006. Date of last inspection 20th June 2005 Brief Description of the Service: 75 Ludford Road is a home that provides care and support for 8 people with mental health issues who are aged between 18 and 65 years. 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 eight single bedrooms. The home in the main is decorated to a high standard. The communal space consists of one large lounge, which is the designated smoking area, there is a lounge / dining area which is non-smoking 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. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection visit was conducted on an unannounced basis by one regulation inspector, all the six residents moved into this home on the 1st February 2006 transferring from another MIND home at 19 Middleton Hall Rd. Three residents were out at the time of the visit, however many residents had met with the inspector on the two inspection visits during 2005, the last being 21st November 2005. The inspector was able to view records pertaining to health and safety, including accidents and fire and also records for the management of residents’ money and their medicine. It is recommended that the last inspection report for 75 Ludford Road dated the 20th June 2005 and the last report for Middleton Hall Rd dated the 21st November 2005 be considered when reading this report. What the service does well: What has improved since the last inspection?
There were few requirements from the last inspection; some of these were environmental improvements, which have been addressed. Other requirements including further developing Essential Life Plans and Risk assessments are no longer applicable as these are and were in place at Middleton Hall Rd. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 6 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 DS0000016868.V285980.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 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 the following standard(s): 2 The home ensures they are fully aware of the residents needs based upon a full and detailed period of assessment, they are then able to make an informed decision as to whether they can meet the residents needs. EVIDENCE: The manager discussed the assessment of one resident who has been referred to the service, this has included attending a Case Conference and the gathering of information from agencies involved with this resident. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 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 the following standard(s): Standards regarding individual needs and choices were not assessed. No judgement. EVIDENCE: No evidence. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 10 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): Standards regarding the lifestyles of residents were not assessed. No judgement. EVIDENCE: No evidence. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 11 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): 20 The practices and policies of the home ensure that medicines for residents are managed safely and in accordance with the prescription. EVIDENCE: Since the transfer to Ludford Road the residents’ are supported by a local chemist and their medicines are prescribed by a local GP and also by a local area community mental health team. The manager is in the process of updating the medicine policy to reflect some changes. Medication administration records are clearly and accurately completed, including when medicine is received, administered and disposed of. An audit of stock for two residents was found to be accurate. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 12 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, 23 Residents’ needs in respect of being protected from abuse are met including safe management of their money. The home if needed can act quickly and are aware of what constitutes a risk to the health and welfare of residents. EVIDENCE: The manager completes a monthly record of any formal complaints and also sends a copy to the MIND head office, there have been no complaints received at the home or at the commission in the past twelve months. A policy is visible for all residents and their representatives to help guide them through the process of making a complaint. The MIND organisation has a detailed policy to ensure that the staff act responsible should abuse be suspected, this policy meets with local multi agency guidelines and describes to staff what they must do. Some residents have money managed by the home and one resident has money managed by MIND as their appointee. Records in the home were found to be accurate, all transactions in and out of the accounts are counter signed by staff, and one resident keeps her own records, which are kept updated. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 13 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 Residents live in a comfortable, safe and homely environment that meets their individual and collective needs. EVIDENCE: Some furniture and fittings have been transferred from Middleton Hall Road, these are domestic in design and are fit for purpose. Carpets in residents’ rooms that presented a tripping hazard have been repaired and some have been replaced. Toilets, bathrooms and showers are clean and tidy with good hand washing facilities; practices are safe to reduce the risk of cross infection and containers for sanitary waste are available. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 14 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): 31, 32, 33, 35, 36 Residents are provided with support from a team of staff who are knowledgeable, well supported and who have an awareness of the changing needs of residents. EVIDENCE: One member of staff described how the manager and the MIND organisation had supported him over many years to achieve through training and development and also how on going support was available on a daily basis if needed and more formally through regular supervision with the manager. The member of staff confirmed achievements to NVQ level 3 and also regular training in safe working practices. The staff rota indicates that after 10pm there is one sleeping care officer on duty, during all day hours there is always a minimum of two care officers and often there are more on duty, including the manager and a domestic who works part time hours Monday to Friday. The inspector was advised on the role of the care officer including a key worker role for one particular resident, the member of staff was alert to possible problems regarding the recent move from Middleton Hall Rd but was also very positive about the benefits for residents. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 15 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): 42 The health, safety and welfare of residents is adequately managed at the home, minor improvements are needed to further promote fire safety. EVIDENCE: The home does have a detailed fire risk assessment, as identified at the last inspection this assessment was in need of review to include findings and compliance checks, this has not been completed. Accidents records are completed for both residents and staff when needed, these records do not indicate any areas of concern, as accidents are not frequent. Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 16 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 2 X X 2 X Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP38 Regulation 23(4) Requirement The fire risk assessment must be reviewed and include details of findings and compliance. Previous timescale of 31/08/05 not met, this requirement is carried forward. Quality reports must be made available on an annual basis and be based upon the respective years quality audits. Standard not assessed and is carried forward. Timescale for action 31/03/06 2 YA39 24 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ludford Road, 75 DS0000016868.V285980.R01.S.doc Version 5.1 Page 18 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
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