CARE HOME ADULTS 18-65
Coriander Close, 79 Northfield Birmingham West Midlands B45 OPB Lead Inspector
Brian Reamsbottom Unannounced Inspection 11th January 2006 13:10 Coriander Close, 79 DS0000017156.V277483.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 Coriander Close, 79 DS0000017156.V277483.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. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Coriander Close, 79 Address Northfield Birmingham West Midlands B45 OPB 0121 457 8257 0121 457 8355 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) Sense West Ms Amanda Wilson Care Home 3 Category(ies) of Learning disability (3), Sensory impairment (3) registration, with number of places Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 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: 79 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 kitchen 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 or aids and adaptations to assist people with impaired mobility. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report must be read in conjunction with the inspection report of 13.06.05. This unannounced inspection took place from 13.10 to 15.45 The inspector met three service users and three members of staff. There was no communication with service users due to their complex needs, therefore were unable to comment on the quality of care. During the inspection the inspector sampled the following records: Care plans, risk assessments, fire, medication records, health and safety and adult protection procedures, daily diaries and medication sheets. What the service does well: What has improved since the last inspection?
The admission policy now clearly states that service users are offered a three month settling in period. The records in the service users’ daily diaries have improved. The record of the food and drink that service users’ have had is now being accurately recorded, showing that service users’ are having a healthy diet. New leisure activities have been introduce for service users to try and see if they like them. The tenpin bowling, the use of the snoozelem and jaccuzi appear to be enjoyed by service users’. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 6 There has been changes in the training department giving staff better access to training, enabling the staff team meet service users needs. 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. Coriander Close, 79 DS0000017156.V277483.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 Coriander Close, 79 DS0000017156.V277483.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): 4, 5 The home has information available to enable prospective service users make an informed decision about living in the home. EVIDENCE: Standards 1 and 2 were met at the inspection of 13.06.05. Standard 4 has now been met. The three month settling in period is now recorded in the admission policy. The two service users’ personal files inspected had an individual contract/statement of terms, conditions and the fees to be paid for the service. It is pleasing to see that management and staff have now addressed the outstanding requirements. Coriander Close, 79 DS0000017156.V277483.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): 7 Care planning and risk assessment practices meet the needs of the service users living in the home. EVIDENCE: Standards 6 and 9 were met at the inspection of 13.06.05. The daily diaries for each service user now clearly state in detail what care has been offered. The authors’ of the records in the daily diaries are not signing their entries. The manager told the inspector that the format for the diaries are in the process of being changed and will include signatures. Members of staff were seen to communicate with service users’ using ‘hand over hand’ method, to ask service users’ what they wish to do during the day. There are records of the involvement of relatives and social workers’ in assisting service users make decisions in their daily lives. Coriander Close, 79 DS0000017156.V277483.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): 17 Service users have access to a range of opportunities to afford them a meaningful lifestyle. A nutritious and varied menu is provided to meet individual dietary requirements. EVIDENCE: Standards 12, 13, 15, 16 and 17 were met at the inspection of 13.06.05. During this inspection service users’ had returned from outings to the local shops and from a drive out. Service users’ had lunch of their choice. The menus showed that the food on offer is varied, nutritious and wholesome. The records of what food is actually eaten by service users’ is now clearly recorded. Coriander Close, 79 DS0000017156.V277483.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): 19, 20 Systems are in place to manage service users healthcare needs, ensuring they receive the healthcare they require. Medication management was generally well maintained, however, to ensure the safety of service users’ great care must be taken in the administration of all medication. EVIDENCE: Standard 18 was met at the inspection of 13.06.05. Health Action Plans are now in place for service users’. They clearly show the input of other professionals, for example, GPs, practice and community nurses, opticians, dentists and pharmacists. The information was detailed ensuring service users enjoy a healthy lifestyle. A suitable cabinet has been purchased for the storage of controlled drugs. There was an incident of a service user not being given his morning medication. A Regulation 37 notification was sent to the CSCI. The advice of the service user’s GP was sought, he advised staff not to give the morning dose but to give the lunchtime dose at the correct time.
Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 12 The management team investigated the incident. The member of staff was not allowed to administer medication on their own until the manager was satisfied that they were competent. The manager has obtained a video and workbooks from Boots, enabling her to periodically test the staff group’s competency in the safe administration and storage of medication. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 13 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): 23 The complaints and adult protection procedures available ensure that service users are protected from harm. EVIDENCE: Standard 22 was met at the inspection of 13.06.05. The home has an adult protection procedure. A copy of Birmingham’s MultiAgency guidelines is available to guide staff what to do in the event of an allegation of abuse. The majority of the staff group have completed training in the Protection of Vulnerable Adults. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 14 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): 30 The home was clean, warm and fit for its purpose and provides service users with a safe, homely and comfortable environment. EVIDENCE: Standard 24 has now been met. The lounge has been redecorated, refurbished and a new carpet has been fitted. Standard 27 has now been met. The seal around the bath has been replaced. The standards of cleanliness in the home are of a good standard. There were no offensive odours at this visit. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 The homes recruitment procedures are robust and ensures that service users are protected from harm Staff have received training to meet the needs of service users. EVIDENCE: The staff presented as interested, motivated and committed to meeting the needs of service users’. There has been one new member of staff commence work since the last inspection. She is presently completing her induction training. On inspecting the personal file it included the following information: Criminal Records Bureau (CRB) disclosure; two references and a copy of the passport. However, there was not a recent photograph. Staff files must include all information and documentation required in Schedule 2 of the Regulations. It is the policy of the organisation to put members of staff forward for NVQ training, after completion of their induction training and completion of the probationary period. The majority of staff have completed NVQ level 2 training.
Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 16 On observation and in talking with the staff on duty, they appeared more relaxed and confident in working with service users’. The manager stated that this is due to being no longer dependent on the use of agency staff. Records of staff supervision sessions show that they are held on a regular basis. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 Outcomes for service users with regards to their health and safety are being upheld by a well managed home. EVIDENCE: The manager is qualified NVQ 4 in management and care. The risk assessments for service users’ activities have been reviewed and updated since the last inspection. Risk assessments for the premises, fire health and safety, food are available. The fire logbook is being accurately maintained all test and checks have been done and recorded. However, the recording of fire instructions and fire drills takes place in the same column. It was not clear if a drill had taken place or that instructions had been given. The inspector advised the manager to create a separate column for each activity, making it clear what activity has actually taken place. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 18 Records of fridge/freezer temperatures and water temperatures are tested and accurately recorded. Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 19 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 X 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X X X X 2 X Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 2 Standard YA7 YA34 Regulation 17(2) 17(1) Sch2 3 YA42 Sch4 (14) Timescale for action The author must sign the records 13/01/06 in the daily diaries. Staff files must include all the 13/01/06 information and documentation required by Schedule 2 of the Regulations. Records of fire instructions and 13/01/06 fire drills must be accurately recorded to show what event has actually taken place. Requirement 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 Coriander Close, 79 DS0000017156.V277483.R01.S.doc Version 5.1 Page 21 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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