Inspection on 12/07/06 for 8 Coriander Close

This inspection was carried out on 12th July 2006.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Coriander Close 24/09/09

8 Coriander Close 03/07/07

8 Coriander Close 01/12/05

8 Coriander Close 06/07/05

8 Coriander Close 03/02/05

8 Coriander Close 22/09/04

8 Coriander Close 14/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Coriander Close, 8 Northfield Birmingham West Midlands B45 0PD Lead Inspector Sarah Bennett Key Unannounced Inspection 12th July 2006 12:30 Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coriander Close, 8 Address Northfield Birmingham West Midlands B45 0PD 0121 453 7292 0121 453 0831 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) Trident Housing Association Vacant Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 1st December 2005 Brief Description of the Service: 8 Coriander Close is registered to offer long-term residential care to five people who have learning and physical disabilities. All of the residents have complex health needs and all are wheelchair users. The home was purpose built in 1995 and is owned and managed by Trident Housing Association. The house is designed on two levels. There is a spacious open plan lounge and dining room and a sensory room. There are two well-equipped bathrooms with mechanical baths, shower trolleys and hoisting facilities to aid lifting. The kitchen is accessed from the lounge area. The first floor is accessed via a stairway. Located on this floor is the office, the laundry and staff facility including a bathroom and bedroom. This floor is not accessible to residents. Currently all communal areas are open plan and there are no private areas for residents to receive visitors apart from their own bedrooms. The fees as stated on the pre-inspection questionnaire completed by the Manager are £810.50. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, a pre – inspection questionnaire completed by the Manager and reports from the provider. One inspector carried out the unannounced fieldwork visit over six and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. The Manager, the Area Manager and the staff on duty were spoken to. Conversations with some residents were limited due to their complex needs and limited verbal communication. The inspector met with all the residents and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? The service users guide has been produced in a way that potential residents can understand easier so they can make a decision about whether or not they want to live there. All residents had care plans so that staff know how to support them to meet their needs and achieve their goals. Care plans had been reviewed and were person centred. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 6 All residents had manual handling assessments so that staff know how to support the person with their mobility and avoid the risks of any injury to the resident or staff. Staff had received training in manual handling so that they have updated knowledge on how to move people safely. Health Action Plans had been developed. This is a personal plan about what a person needs to stay healthy and what support they need to go to healthcare services. All staff had received training in adult protection and preventing abuse so they know how to protect residents from this. Staff had received the necessary training so that they can meet the needs of the people who live there. A Manager had been recruited to work at the home. They lead staff so that individual’s needs are met. 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, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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): 1, 2, 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether or not they want to live in the home. Prospective residents needs and goals are assessed before they move in to see whether it is a suitable place for them to live. Each resident had an individual contract that states the terms and conditions of their stay at the home. EVIDENCE: The statement of purpose of the home had recently been updated to include the appointment of the new manager. It included all the relevant and required information. The Manager said that the service users guide is currently being put into a Widgit format to make it accessible to potential residents. In this format it would not be accessible to the current residents. It included all the relevant and required information. The admission procedure included an assessment of the individual’s needs to ensure that the home can meet their needs before they move in. Since the last inspection no residents had been admitted. At the last inspection it was found that a detailed assessment on a resident had been completed prior to them moving into the home. This included input from their advocate. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 9 Residents records sampled included a Licence Agreement. These stated the terms and conditions of residents stay at the home including their rights and responsibilities. These were signed and dated by the previous manager. The resident or their representative where appropriate, should also sign these. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff had the information they need to know how to support each resident to meet their needs, goals and aspirations. Residents are supported to make choices about their day-to-day lives. Residents are supported to take risks within a risk assessment framework. EVIDENCE: Two residents records were sampled. Records included a detailed individual care plan. They stated how staff are to support the individual with their communication, personal care, self-help skills, medication, leisure and day opportunities, religion, contact with family and friends, mobility, health needs and dietary needs. Plans were person centred and staff had received training in this from the British Institute of Learning Disabilities (BILD). Due to the complex needs of the residents it can be difficult for them to make choices and decisions about their lives. Staff were observed supporting individual residents to make choices about their day-to-day lives. This included what they wear, eat, what activities they took part in and where they spent Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 11 their time. One resident has an independent advocate. Staff said that their advocate is always invited to their reviews, as are relatives of other residents. One resident is a representative on the Trident service user group. This is chaired by the Trident Service User participation Officer. It is positive that residents who have limited verbal communication skills are included in this group. Resident’s records sampled included individual risk assessments. These were detailed and stated how staff are to support the person to minimise the risks involved at night, if there is a fire, using bedrails, eating and drinking, using the snoozelen room, bathing, swimming, using the kitchen and using a wheelchair. These had been regularly reviewed and updated where necessary. Some residents receive their food through a PEG tube. One resident’s manual handling assessment stated that because of this they should not lie flat on their bed or the shower trolley to avoid the risk of choking. This was not included in their night support risk assessment and should be so that it is clear to all staff at all times. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15, 16, 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living at the home experience a meaningful lifestyle. EVIDENCE: Residents go to day centres from Monday to Friday and are transported there and back by staff from the home. One resident had been to the ‘Taste of Birmingham’ show at Canon Hill Park the previous weekend. They had travelled there supported by staff using wheelchair accessible public transport. Daily records sampled showed that residents go shopping, to the hairdressers, to discos and the Botanical Gardens. Inside the home residents listen to music, spend time in and help to water the garden, help to tidy their bedroom, have a hand massage, use a foot spa, have a hydro bath, play ball games and use sensory and tactile items. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 13 The Manager said that through doing the person centred plans staff had found out more about the tastes and interests of individuals. One person likes classical music and had been to concerts at the Symphony Hall. Another person liked listening to the ‘Black Eyed Peas’ and staff were finding out if they were touring locally. Records were very detailed about the individual’s day, their response to activities and how staff had assessed this through the individual’s non-verbal communication such as smiles, gestures and whether or not their body was relaxed. Minutes of staff meetings showed discussions about resident’s holidays. The Manager said that staff are supporting three residents to go to Burnham –on – Sea in Somerset and two residents to go to Blackpool. Residents records sampled showed that staff support residents to maintain contact with their family where appropriate through visits, telephone calls and sending cards for special occasions. One resident has an independent advocate. Relatives and the advocate are invited to residents review meetings. The Manager said that through developing individual person centred plans staff had talked to relatives about the background of individuals that is important to how staff support them to meet their cultural needs. Residents are supported to be as independent as possible. Staff were observed encouraging residents to hold their drink if they were able to. Care plans sampled stated how staff are to encourage individuals to develop their independence skills when bathing and their personal care. Care plans stated that staff are to involve the individual at all times noting their vocalisations, body movements and expressions as to how they might be feeling and that they could participate through smell, touch and sound. Residents have access to all communal areas of the home although this is limited, as they need support from staff to do this. Staff were observed changing the position of where residents were sitting so that they had a choice of being in their bedroom, in the communal areas, on the floor if that was safe for the person or the garden. Two residents receive their food through a PEG tube. Menus seen showed that a variety of food is offered to the other residents. A wide selection of fresh fruit and vegetables were available. Adequate and varied food stocks were available as were a wide variety of breakfast cereals. Staff sat with residents to support them appropriately during their evening meal. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their health needs are generally well met. Arrangements are in place to ensure that the management of the medication protects residents. EVIDENCE: Residents care plans stated how staff are to support the individual with their personal care. One care plan sampled stated that it was not acceptable for staff to purchase clothes for the person without their involvement. The care plan was detailed as to how the individual’s hair, skin and nails are to be cared for in relation to their cultural background and individual needs. It stated that the person should be involved at all times during their personal care and because of their communication needs this may be through smell, sound and touch. Care plans detailed step-by –step information about supporting individuals with their personal care. Residents were well dressed in good quality clothing appropriate to the weather, their age and the activities they were doing. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 15 One resident was supported to get out of their wheelchair by staff using the hoist to spend some time mobilising on the floor. Staff put mats down on the carpet to protect the resident who seemed very happy to be out of their wheelchair. Staff were observed to support the resident appropriately and talked to them while using the hoist ensuring that they knew what was happening and where they were being moved to. As it was a hot day when residents went into the garden staff made sure that they sat under the parasol and their sunglasses were put on to protect them from the sun. Residents were supported to change into cooler clothes when they came home from the day centre. Fans were used and positioned near to residents who had difficulty cooling down. Since the last inspection staff had developed individual Health Action Plans for residents. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. These had been hand written and the Manager said that they are going to type them before putting them in individual files. These were detailed and stated what the person needs to be healthy and what help they need to do this. Where appropriate health care professionals are involved in the care of residents. These include the Speech and Language therapist, Reflexologist, Dietician, Occupational Therapist, District Nurse, Physiotherapist and the Psychiatrist. Records showed that residents had regular check ups with the chiropodist, dentist and optician. One resident’s records included a pressure area assessment dated January 2002 that stated that the person was at very high risk of developing a pressure sore. However, this had not been reviewed since to ensure that all the risks are minimised as much as possible. The Speech and Language Therapist has been invited to the next staff meeting to discuss with staff how to communicate with one resident using objects of reference for example showing the person a cup for a drink. At previous inspections staff had raised concerns about the medication cabinet being upstairs as two staff are required to do the medication and so staff cannot be downstairs observing the residents. A requirement was made to provide a medication cabinet in each resident’s bedroom. Following risk assessment staff had agreed that this was not necessary and would be institutionalised detracting from the homely feel of the home. There is always a member of staff downstairs whilst staff are administering medication. One resident had their own medication cabinet in their en suite. The medication cabinets were clean and organised. The Medication Administration Records (MAR) had been signed appropriately indicating that medication had been given as prescribed. At the front of each residents MAR Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 16 there was a photograph of the individual so that if staff giving the medication do not know the residents well it is clear which resident to give it to. Where residents are prescribed PRN (as required) medication a protocol is in place stating when, why and in what dosage the medication should be given. These are signed by the GP. One resident is prescribed ‘rescue’ medication in case of having several epileptic seizures. A protocol for giving this is in place and staff had received training in how and when to give it. Staff check this regularly and a record kept to ensure it is used appropriately. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 17 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 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents and their representative’s views are listened to and acted on. Arrangements are in place to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The pre-inspection questionnaire stated that there had been no complaints about the home in the last 12 months. The CSCI had not received any complaints. Each resident had a copy of the complaints procedure. This is produced using symbols to make it easier to understand. It includes details of how to contact the CSCI and states that this can be at any time if not satisfied with the home and the service provided. Staff records sampled showed that all staff had training in adult protection and the prevention of abuse in March 2006. Resident’s records included an inventory of their belongings. This was detailed but not dated so it was not clear when the resident had bought or disposed of items. Two residents financial records were sampled. The money in their individual tin cross-referenced with the amount on their financial record. Receipts are kept of all purchases. Resident’s money had only been used to buy personal items not for anything to do with the running of the home. Each day at the handover of shifts staff check the monies held to ensure they are correct. Regular financial Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 18 audits are completed to ensure that personal monies are being used and recorded appropriately and that receipts cross-reference with the record. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 19 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, 27, 28, 29, 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, homely, safe and comfortable environment that generally meets their individual needs. EVIDENCE: The home is generally well decorated and maintained. Some of the paintwork at the bottom of the walls in the lounge and around doorframes was worn and in need of maintenance. There were modern pictures hanging on the walls of the lounge and dining room that reflected the age of the people who live in the home. Resident’s bedrooms seen were well decorated according to individual’s tastes, interest and age. Bedrooms contained several personal possessions. At the last inspection a requirement was made for the equipment in the sensory room to be repaired. The Manager said that a date had been booked for this to be repaired so that the room can be used which would benefit the residents. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 20 In the dining room there was a ‘hammock’ chair. The Manager said that it had been given to one of the residents but was not suitable for them to use it or any of the other residents. As it is the resident’s property it is not possible to just dispose of it so the Manager is looking to see if anyone at the day centre that residents go to would benefit from using it. It takes up quite a bit of room in the dining room so this needs to be considered to give the residents more space. There is a large garden at the back. There were attractive hanging baskets and a large parasol for residents to sit under to have shade from the sun. There are some attractive flowerbeds but these are not raised so are not easily accessible to the residents. The Manager said that funding is available to raise one of these beds, which would be made into a sensory herb garden to benefit the residents. The Manager said that they hope to get a pagoda put up so that there are more areas where residents can sit in the shade. One resident has an en suite shower room with WC. A requirement was made at previous inspections for the en suite to be refurbished. However if a shower were to be provided they would not be able to access it because it is not big enough to put in a hoist as well as transfer the person from their wheelchair to the hoist. They use the wash hand basin. The person prefers to have a hydro bath and does not like showers but the en suite is too small for a hydro bath. Therefore, it was agreed that as providing the facilities would not benefit the person this requirement would be withdrawn. In the future if the individual moves from this bedroom this would need to be reconsidered. There are two bathrooms each of which has an accessible bath and a shower. The home was clean and free from offensive odours. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35, 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development was variable. EVIDENCE: The pre-inspection questionnaire stated that 70 of care staff had completed training in NVQ level 2 or above in Care. This exceeds the standard that at least 50 of staff have received this training. Rotas showed that minimum staffing levels are met. The pre-inspection questionnaire stated that two part-time staff had left since the last inspection. Regular bank and agency staff are usually cover the vacancies. On the late shift there were two agency staff and one permanent staff. One of the agency staff had not worked there before. The Manager said that this situation rarely occurs and was because a regular agency staff had cancelled their shift. Rotas sampled confirmed that regular agency staff are used. The Manager said that usually before agency staff work at the home, they visit for an induction. The organisation is trying to recruit regular agency staff to permanent contracts so to offer a more consistent service. Minutes of staff meetings showed that these are held about every two months. The Manager said that these would be held monthly on the future. Minutes Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 22 sampled showed that the discussions at the meetings were focussed on the needs of individual residents. Three staff records were sampled. For one of these staff recruitment records were not available in the home. The Manager said that these are at Head Office and he had emailed them to ensure they are held in the home and now needs to go and collect them. The other two records included a completed application form, proof of identity, evidence that they are physically/mentally fit to do the job they are employed to do, two written references and evidence that a Criminal Records Bureau (CRB) check had been undertaken. One of the records did not include a recent photograph of the person as required in the Regulations. Staff training records showed that staff had received training in food hygiene, first aid, fire safety, manual handling, adult protection and the prevention of abuse, health and safety and epilepsy. The Area Manager said that all staff had received training in administering PEG feeds and dysphagia. However this was not evident in individual training records. All training that staff have received must be recorded so that it is clear whether there are gaps in the skills and knowledge of individual members of staff. Supervision records sampled showed that staff had not received regular, formal, recorded supervision sessions with their manager. The home had been without a manager for about a year. The Manager has now put in place a supervision plan and is to offer formal supervision to all staff each month. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 23 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, 39, 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appointing a Manager has improved the management arrangements to ensure that residents benefit from a well run home. Registration with the CSCI will ensure that this arrangement is consistent and further improves this. Arrangements are not sufficient to ensure that residents or their representative’s views underpin all self-monitoring, review and development by the home. Arrangements are in place to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: The Manager had worked at the home for four weeks. During that time he had spent time getting to know the residents and staff and prioritising the management tasks. It was evident that he knew the needs of individual residents well and was communicating this to the new agency staff working on the afternoon shift. The Area Manager said at the end of the Manager’s Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 24 probationary period they would hope to be making an application to be registered with the CSCI. The Manager has several years of experience of managing a care setting although had not worked with people who have a learning disability for some time. The Area Manager was aware of this when recruiting and during their supervision agreed to ensure that any gaps in their skills and knowledge would be filled. The Manager has NVQ level 4 in Care and is planning to start the Registered Managers Award in the near future. A representative of Trident visits the home monthly and completes a report of their visit that is forwarded to the CSCI. During these visits they consider the views of residents and staff. The organisation has a comprehensive quality assurance system. However, the Area Manager said that it had not been implemented in this home. Fire records showed that regular fire drills are held so that staff and residents know what to do if there is a fire. The fire risk assessment had been recently reviewed to ensure that all the risks of a fire starting are minimised. Staff test the fire equipment regularly to make sure it is working. An engineer regularly services the fire equipment. A Corgi registered engineer tested the gas equipment in June and stated that it was in a satisfactory condition. An electrician tested the portable electrical appliances in June to make sure that they are safe to use. An electrician completed the five yearly electrical wiring test on 14th June. There was some work that needed to be done to ensure that the system meets current regulations so a certificate of this was not available. The Manager said that once this is completed they would fax the certificate to the CSCI. Staff test the water temperatures weekly to make sure they are not too hot or cold. The last test showed that temperatures ranged from 41-42 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. Staff test the temperature of the fridge daily and records showed that this tested within the safe limits for food storage. Records showed that an engineer regularly services the hoists and adapted baths. The resident’s wheelchairs are regularly serviced to make sure they are safe to use. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 5 2 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 2 25 X 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 3 X Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 26 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. Standard 1. YA19 Regulation 12 (1) (a) Requirement Resident’s pressure area assessments must be regularly reviewed and updated where necessary. All the equipment in the sensory room must be in working order. Outstanding from last inspection. The ‘hammock’ chair must be removed from the dining room to provide more space. Staff vacancies must be recruited to. A recent photograph of all staff employed must be available in the home. All the required records pertaining to the recruitment of staff must be available in the home for all staff employed there. A record of all training that each member of staff has received must be available. All staff must receive, regular, formal, recorded supervision sessions at least six times a year. The Manager must make an application for registration with DS0000016935.V298861.R01.S.doc Timescale for action 12/08/06 2. YA24 YA29 23 (2)(c) 31/08/06 3. 4. 5. YA29 YA33 YA34 23 (2) (g) 18 (1) (a, b) Sch 2 (1) 17/09/06 31/10/06 31/08/06 6. 7. YA35 YA36 Sch 2 (4) 18 (2) 31/08/06 30/09/06 8. YA37 8 9 31/10/06 Coriander Close, 8 Version 5.2 Page 27 the CSCI. 9. 10. YA39 YA42 24 (1) (2) (3) 13 (4) (a-c) The quality assurance system must be implemented. A copy of the electrical wiring certificate must be faxed to the CSCI. 30/09/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA5 YA9 YA23 Good Practice Recommendations The resident or their representative should sign the licence agreement. One residents risk assessment re: not lying flat on their bed or the shower trolley should be included in their night support assessment. Inventories of resident’s belongings should be dated. Coriander Close, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 28 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 © 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, 8 DS0000016935.V298861.R01.S.doc Version 5.2 Page 29 - 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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