Inspection on 13/06/05 for 79 Coriander Close

This inspection was carried out on 13th 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

79 Coriander Close 25/01/07

79 Coriander Close 11/01/06

79 Coriander Close 03/02/05

79 Coriander Close 15/09/04

79 Coriander Close 10/03/04

79 Coriander Close 02/10/03

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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 79 Northfield Birmingham B45 0PB Lead Inspector Brian Reamsbottom Unannounced 13th 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 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 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Coriander Close, 79 Address 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 457 8257 0121 457 8355 Sense West Amanda Wilson (Acting) Care Home 3 Category(ies) of Care Home registration, with number of places Coriander Close 79 E54_S17156_Coriander79_V233171_130605 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 3.02.05 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 E54_S17156_Coriander79_V233171_130605 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 and a half hours. The inspector met three service users and three 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, medication records, 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: 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 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 6 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 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 7 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 and 4 The home has information available to enable prospective service users make an informed decision about living in the home. EVIDENCE: The Service User Guide is available on compact disc (CD) in a pictorial format to meet the needs of service users. This is to be commended. There have been no new admissions to the to the home since the last inspection. The two service users files inspected had a full assessment in place. The admission policy must clearly state that service users must be offered a three month settling in period. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 8 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 and 9 Care planning and risk assessment practices meet the needs of the service users living in the home. EVIDENCE: The two 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. The care plans were comprehensive and had good detail on how the needs of service users were to be met. Records included an activity timetable for each service user. In the daily diaries inspected there were statements of ‘assisted’ with having a bath. Detail of what assistance was given must be recorded. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 9 The risk assessments are in the process of being further developed. There was 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. The staff team were observed to have developed good relationships with service users and were attentive to their needs and wishes. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 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 standard(s) 12 13 14 15 and 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: Service users access local shops, cinema, social clubs and library. Visits are made to the local pub for a drink and a meal. Service users have weekly sheets showing the activities in the home and away from the home, for example, swimming, horse riding, massage, aromatherapy and tenpin bowling. They make use of an adult soft play centre in Wolverhampton. During the inspection service users were coming and going from their daily activities in the community. A service user had been to an aromatherapy session and went to rest in her room, other had a meal out or a swimming session. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 11 Service users are having a holiday in Wales Good contact is being maintained with family and friends. Visits are made to the parental home on a regular basis, family visit the home. The staff keep in contact with families by letter and the telephone. The menus showed that the food is varied, wholesome and nutritious. Records are kept of the actual food eaten by service users. However, on occasions there were gaps in the information recorded. Records must be maintained to enable any person inspecting the record to determine whether a diet is satisfactory. One service user has a separate menu for health reasons. The diet was introduced with the assistance from a dietician. The service user is making good progress with the changes in his eating habits and is well supported by the staff team. Exercise has been included in his health regime. He makes use of a walking machine for twenty-five minutes a day, supervised by a staff member. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 and 20 The medication management is good ensuring service users receive medication as prescribed. Systems are in place to ensure that service users receive the care they need. EVIDENCE: The two care plans inspected showed that personal care is given daily in a manner liked by service users. Personal care is given behind closed doors, in toilets, bathrooms and bedrooms. Service users have their own routines that they follow and are respected by the staff group. Service users choose their own clothing that they wish to wear from their wardrobes. The format for Health Action Plans was seen, they are in pictorial and written formats to meet the needs of service users. Approval for their use is to be made by senior management in the near future. The management of medication is good. A Monitored Dosage System (MDS) is in place. There are protocols for ‘as required’ (PRN) medication. A Pharmacist from the supplier of the MDS visits the home on a regular basis giving support in the safe administration and storage of medicines. Medication is safely stored in an appropriate cabinet. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 13 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. 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. Medication was administered as directed, the Medication Administration Records (MAR) confirmed this. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 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. The complaints procedure is now available in pictorial and audiotape formats to meet the needs of service users. This is to be commended. 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 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 27 The home was clean, warm and fit for its purpose and provides service users with a safe, homely and comfortable environment. EVIDENCE: 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. However, the service users appeared content in their surrounding and were observed to move around the home with assistance from the staff. The home is very much the service users. The service user’s bedrooms were very individual in décor and furniture, reflecting their personalities. The seating and the floor covering in the lounge are being replaced. The seal around the bath is no longer fit for its purpose and must be replaced. Water is getting between the bath and the wall and may give rise to damp and smells. The home was clean, hygienic and free from offensive odours. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 16 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) 34 and 35 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 two staff files that were inspected did not have a recent photograph or a CRB check. Staff files must include all information and documentation required in Schedule 2 of the Regulations. On discussing training with a staff member it is evident that the organisation is committed to training. The organisation’s training department provides training for all staff. Members of staff have done statutory training. The majority of the staff group have completed NVQ training to level 2 or 3. The staff presented as being knowledgeable of the service users needs. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The home is well managed and promotes the health and safety of service users. EVIDENCE: The home has a range of policies, procedures and systems in place to comply with the requirements of health and safety legislation. Risk assessments are in place for the premises, fire, food, hygiene and service users. Records of testing of electrical, fire and gas equipment were seen to be in order. Water and fridge/freezer temperatures are tested on a regular basis and a record kept. The emergency lighting test was overdue and must be tested as a priority. A Controlled Drugs cabinet must be purchased. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 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 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 4 x x 2 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coriander Close 79 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 19 no 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. 2. 3. 4. Standard YA4 YA 20 YA 27 YA23 Regulation 1.(4)(i) (c)(8) 13.(2) 23.(2)(j) 13.(6) Requirement There must be a three month settling in period followed by a review with service users. An appropriate medicine cabinet must be purchased for the safe storage of Controlled Drugs. The seal around the bath must be renewed. The adult protection procedures must reflect the Multi-Agency Guidelines. Timescale for action 31 July 2005 30 August 2005 30 June 2005 30 June 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. 1. Refer to Standard YA 19 Good Practice Recommendations Implement health action plans for service users. Coriander Close 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street 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 79 E54_S17156_Coriander79_V233171_130605 Stage 4.doc Version 1.30 Page 21 - 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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