Inspection on 19/05/08 for 807 Pershore Road

This inspection was carried out on 19th May 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

807 Pershore Road 21/06/07

807 Pershore Road 04/10/05

807 Pershore Road 21/04/05

807 Pershore Road 07/12/04

807 Pershore Road 14/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Pershore Road (807) Selly Park Birmingham West Midlands B29 7LR Lead Inspector Kevin Ward Key Unannounced Inspection 19th May 2008 08:00 Pershore Road (807) DS0000016858.V364842.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 Pershore Road (807) DS0000016858.V364842.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. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pershore Road (807) Address Selly Park Birmingham West Midlands B29 7LR 0121 415 5684 0121 415 5684 pershore@mind-birmingham.co.uk 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 Mr Martin McKinley Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That two named people, who are over sixty five years of age can be accommodated and cared for in this Home. 21st June 2007 Date of last inspection Brief Description of the Service: 807 Pershore Road is a large detached double fronted three storey, Victorian style property in Selly Park. The home was providing rehabilitation services as opposed to long stay placements for younger adults with mental health needs. Places were provided for time limited rehabilitation, and the people accepting a service at the home were expected to move on within eighteen months of being placed at the home. The home is well placed in terms of access to the local community, being close to a number of shops, pubs, park, Stirchley village and local bus and rail services. The front of the house has a well-maintained walled garden, which provides parking for some cars, the rear garden is large and very private and is utilised by the people living in the home in the summer. The house feels spacious and homely; it appears to be a well established home with a clear philosophy of care that clearly suits the service user group. All bedrooms are of single occupancy and two have en-suite facilities. There are showering/bathing facilities on each floor and toilets are shared by no more than three people. There are also kitchenettes on each floor for the use of the people living in the home. Communal space comprises of two large lounges, one smoking and one non smoking and a large dining room which are all located on the ground floor. Also located on the ground floor are a laundry, main kitchen and small office. The service user guide was not available at the time of the site visit. The home should be contacted for information on current fees. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use the service experience adequate outcomes. This was a Key unannounced inspection which addresses all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for the people using the service. The inspection focused on assessing the main Key Standards. As part of the inspection process we reviewed information about the home that is held on file by us, such as notifications of accidents, allegations and incidents. The manager completed and returned an annual quality assurance questionnaire, containing helpful information about the home. The inspection included meeting everyone living at the home and case tracking the needs of two people. This involves looking at their care plans and other records and checking how their needs are met in practice. Three people at the home also completed and returned questionnaires giving their views on the home. Discussions were also held with staff on duty and the assistant manager. Following the site visit a telephone discussion took place with the Registered Manager, who is currently on a temporary secondment to another post in the organisation but visits the home at least once a week. A number of records, such as care plans, complaints log, staff training records and fire safety log were also sampled for information as part of this inspection. What the service does well: When people are thinking about moving to the home their needs are assessed and they are able to visit the home on several occasions before deciding to move in. This gives everyone chance to get to know each other first. The people at the home spoke highly of the support provided by staff. One person said “staff are really good and have really helped and showed me different ways of doing things”. Another person said, “The staff are great”. Everyone is encouraged to take part in planning for their futures and to take responsibility and control over their lives. They are able to attend meetings at the home to discuss the everyday running of the home and consider how it may be improved. One person said “staff ask for suggestions to help make things better”. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 6 The people at the home take part in shopping for their own groceries and for cooking their own meals. Staff support is freely provided, where necessary, to help people to develop these skills. People are free to come and go from the home as they please and have keys to let themselves in and out of the home and to lock their bedroom doors. Everyone commented on the pleasant atmosphere in the home and said they felt safe at the home. Staff treat people in a friendly manner and show them respect, e.g. they do not enter their bedrooms uninvited. The home has good links with Mental Health workers, such as psychiatrist and nurses. Where necessary people are assisted to gain access to other health professionals to help to meet their health needs. Staff at the home encourage and support people to manage their own medication in a safe manner. Suitable complaints procedures are in place and the people at the home know how to raise their concerns with staff and the manager. Staff have previously been trained to recognise and report any suspicions of abuse so that people are protected from harm. Staff are provided with training to do their jobs. Almost everyone now holds National Vocational qualifications in care. Regular monitoring meetings are carried out by committee members of MIND, to check that people are happy at the home and to pick up any issues that need to be addressed. What has improved since the last inspection? What they could do better: Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 7 The service user guide was not available as the Registered Manager is in the process of updating information about the home. He has agreed to complete this work quickly so that it is available again for people moving to the home. Some important information about how to support people and manage risks safely is missing from care plans and risk assessments. This needs to be improved to ensure that staff have all the information they need to ensure that people are supported safely. Overall the home looks nice but the staircases are still in need of decorating to make the place look better for people. There is a need to provide a lot of staff with food hygiene training as they have not had this training recently, to ensure that good food hygiene standards are upheld at the home. The Registered Manager has agreed to send us a letter to keep us informed of the length of time he will be away from the home on a secondment to confirm the management arrangements in his absence. 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. The summary of this inspection report can be made available in other formats on request. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 8 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 Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable admission arrangements are in place to help people to make an informed decision to move to the home. Written information about the home is currently not available and is being updated. EVIDENCE: There have been no changes to the service provided at the home. A staff member confirmed that the home continues to provide time limited rehabilitation, and the people accepting a service at the home were expected to move on within eighteen months or so of being placed at the home. The people at the home confirmed that they were given information about the service before they moved in to help them to know what the home has to offer. Similarly several people spoken to said that they had been supported to visit beforehand to help them to move in gradually. Further evidence of this was seen in two people’s admission records. The files also included assessment forms, containing people’s needs and aspirations, which had been completed as part of the admission process. This enables the home to check that they can meet the needs of people before they move in. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 10 Both files contained licensee agreements that had been issued to them by the landlords explaining the terms and conditions of their stay at the home. The acting manager said that the Registered manager has taken the Statement of Purpose and the service user guide off site to another office to update the information to accurately reflect the current situation in the home. In a telephone conversation with the Registered Manager, following the site visit, he agreed to update the information promptly and return it the home. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is significant scope for increasing the level of detail contained in care plans and risk assessments, so that staff have clearer information by which to support the people at the home. People are encouraged to make everyday choices and plan for their futures so that they can exercise control and responsibility over their lives. EVIDENCE: Two people’s care plans were examined. The care plans are called Essential Lifestyle Plans. These plans are completed by the people using the service and provide information about people’s needs and state broadly how they expect their needs to met. These plans are person centred and are a good way of encouraging people to take control of their rehabilitation. One of the plans contained very broad information and little detail about how the needs identified are actually met in practice, e.g. no mention of what groups are attended, details of budgeting support and what support is necessary from staff to maintain good mental health. The other plan was more detailed and Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 12 contained more advice for staff to follow. Review records indicate that the information in care plans is being regularly checked to ensure it is still relevant. Both people’s files contained monthly reports that summarise significant events and clarify plans for the coming month, indicating that people’s progress is being supported and monitored by staff. Similar differences were found in the level of detail in the risk assessments. One person’s risk assessments contained good levels of information to help staff to recognise and deal with matters such as self neglect, whereas the other person’s failed to provide any detailed guidance for staff to follow. The acting manager agreed to arrange for more detailed information to be included in the care plans. There was no information in the risk assessments seen about how to respond to any challenging behaviours that may be presented. This is important so that staff can be aware of triggers for behaviours and how to respond in a safe manner, where necessary. Discussions with staff demonstrated that they had a good knowledge of people’s support needs and of their levels of independence. A member of staff and the acting manager were able to demonstrate a good awareness of presenting symptoms and behaviours that would indicate a relapse in people’s mental health. The manager agreed to update people’s care plans so that new staff can benefit from this knowledge. Everyone at the home spoke highly of the staff and felt well supported. Everyone at the home confirmed that they are free to make everyday living choices, such as what they eat and what they do, e.g. what courses they attend and who they see. People confirmed that they do their own grocery shopping and receive budgeting support and advice from staff where necessary. Staff were seen to remind someone of an appointment they had planned so that they could choose to attend or not. The people at the home confirmed that they are totally involved in planning their futures as well as their day-to-day lives. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged to retain and develop their independence and to take control of their lives so that that they may be equipped for independent living in the future. EVIDENCE: The people at the home confirmed that they are supported to maintain their independence to make use of the local community. People were seen to venture out as they wished with no unnecessary restrictions. The people at the home have a key to let themselves in at night, as well as keys to their bedrooms and a security box in which to keep their money and medication safe. People are provided with information about relevant support groups for them to consider and encouraged to take personal responsibility for their lives. Several people spoke of plans to move out to other accommodation and evidence of support to do so was seen in people’s records. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 14 One person explained how he generally likes to stay in with friends and enjoys the Sunday lunch at weekend when everyone gets together. Some people enjoy playing music and two people have been active in writing their own music using computer equipment. One person also said that they were learning to play a musical instrument and enjoy going places to hear music. A variety of opportunities for college courses, day centres, and days out were made available for the people living in the home. Several people spent part of their day at day services and courses on the day of the site visit. Everyone confirmed that staff are available to provide support where required to do so. One person explained that they had been helped by staff to attend an interview when first returning to work, which is now going well. Several people confirmed that they are in touch with relatives and friends and are able to receive visitors at the home. This was verified in people’s records. People are able to see relatives in their own rooms but the manager explained that for security reasons general visitors are required to stay in the down stairs lounge. Two people received visitors during the time of the site visit. Both visitors spoke positively about the manner in which they are welcomed by staff. One person had just returned from a week’s holiday abroad, which they had enjoyed very much. “Resident meetings” take place at the home and a run by the people that live there. Comments by people at the home indicate that the meetings are useful and that the staff and the manager take suggestions arising seriously. A person explained that the meetings have previously been used to raise concerns about the conditions of the kitchenettes, which have since been improved, as well as agreeing everyday living arrangements, such as cleaning kitchenettes after use. People living in the home were taking responsibility for cleaning their own rooms, doing their own laundry and cooking most of their meals. People confirmed that support from staff is freely given where required. Everyone at the home said that they shop their personal groceries and cook their own meals. Several people confirmed that they have sufficient money to buy the food they like. Bread and milk is also provided by the home. People confirmed that they are encouraged to eat healthily but ultimately the choice is their own. One person explained that they had changed their eating habits on the advice of staff and now eat less high fat convenience foods and feel better for it. Everyone has their own lockable cupboard in which to store their food and a personal shelf in the fridge. Several people commented that they do not need to lock the cupboards as everyone currently at the home respects each others belongings, including food. A communal lunch is cooked with staff involvement Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 15 on Sundays. A number of people said how much they enjoyed Sunday lunches together. Kitchenettes are available on the two upper floors of the home and there is a main kitchen on the ground floor, providing sufficient space for people to prepare their meals. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have a good understanding of the personal and health care needs of the people living in the home and ensured these were met whilst maximising their independence and control over their lives. There is potential for people’s care to be compromised by shortfalls in care plans and protocols. EVIDENCE: Everyone at the home attends to their own personal care needs and do not require any practical assistance from staff. Everyone at the home confirmed that they take responsibility for purchasing their own clothes and one person said they sometimes like to seek the opinion of staff when shopping for clothes. One person at the home went shopping and returned with new clothing during the course of the site visit. There is one female at the home. She indicated that she is happy at the home and is treated respectfully by other people at the home and the staff that work there. She also confirmed that she is being supported to plan for her future. Evidence of support given to look at other places to live was also seen on file. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 17 Everyone commented positively about the support provided by staff and indicated they find them to be fair, friendly and approachable. Everyone commented positively on the supportive atmosphere in the home. A number of people said that they felt safe and happy with the other people living at the home. A person at the home expressed concern about an increase in their weight that is believed to be associated with changes in medication. The records show that the person concerned is having their medication properly reviewed by health professionals. The manager said that she intended to request a GP referral for dietician advice to provide further support in this matter. People’s files show that they have been supported to register with local GP’s and dentists. People at the home confirmed that they make their own choices about whether or not they attend check ups or not but that the option is made available to them to consider. As previously noted some of the information in people’s care plans (Essential Lifestyle Plans) is very broad and not well detailed. There is no clear information to advise staff of the signs and symptoms to look out for that might indicate a relapse in mental health. However comments by the acting manager and staff indicated a good understanding of people’s needs. This could compromise care in future, as new staff may not be as well informed about people’s needs. Comments by the staff and the manager confirmed that everyone is currently well and their mental health is good. People’s records show that reviews are carried out with the involvement of Community Psychiatric Nurses as part of the package of support available to people and the manager confirmed that she is able to access good support where necessary in the event that there is a relapse in people’s mental health. People at the home take responsibility for managing their own medication with varying levels of support from staff, where required. Risk assessments are carried with people to determine the level of support people require to manage their medication (seen on file). The medication file also includes instructions for staff regarding the support each person requires with their medication. Some people are totally self-administering, and others are supported by staff to fill their weekly cassettes and then see to staff to administer their medication. A running record is kept of PRN (as required) medication given to people so that every tablet can be properly accounted for. A person’s tablets were counted and found to tally correctly with the record. Daily checks of the medication are carried out at shift handover time so that any discrepancies may be picked up promptly. The manager said that no one at the home Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 18 currently takes PRN medication for mental health relapses. The acting manager agreed to devise PRN protocols in the event that anyone has PRN medication prescribed for this purpose, in order that staff are clear about the circumstances under which the medication should be given and what other measures to try first, e.g. staff counselling people. A member of staff explained that she had previously had medication training and is currently completing distance learning training, which includes an assessment workbook. The acting manager reports that all the staff are currently doing this training. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with procedures and training to enable them to respond appropriately to service users concerns and to protect them from harm. EVIDENCE: There have been no complaints to us about the home since the last inspection. There has been one complaint to the manager, made by a person at the home concerning the conduct of another person living there. The complaint has been properly recorded and action to taken to resolve the matter in an amicable way. Everyone at the home said they know how to complain and indicated they felt their concerns would be taken seriously and followed up by the staff and the manager. A member of staff confirmed that she had been provided with adult abuse training and had seen the whistleblowing policy. A staff member was able to show a good understanding of how to report any concerns she might have for people’s welfare. The acting manager confirmed that there have been no adult abuse investigations at the home during the last year. Staff training records demonstrate that all except one member of staff have had adult abuse training previously. As it has been three to four years since most staff have had this training, the acting manager agreed to seek training updates for staff at the home. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 20 Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have taken place at the home so that people benefit from well maintained comfortable accommodation. EVIDENCE: A tour of the communal areas of the home was made and two bedrooms were seen. There had been no changes to the layout of the home since the last inspection, which was generally comfortable and well maintained. Everyone spoken to said that they were happy with bedrooms and felt that staff respected their privacy. Everyone confirmed that they are encouraged take responsibility for keeping their bedrooms clean. The assistant manager carries out regular 2 weekly Health and Safety audits (copies of which were seen on file ) which includes checking people’s bedrooms are safe. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 22 There is ample communal space for all people to relax in and there are designated with designated dining and smoking areas. The dining room also housed a pool table and telephone for the use of the people at the home. People at the home confirmed that the carpets and the furniture are regularly cleaned to keep them in decent condition for people and proper cleaning equipment is available for purpose. Both lounges were equipped with televisions and music systems. The staircases would benefit from redecoration. The assistant manager said that she had been seeking quotes to have this work done at a reasonable price. There were adequate numbers of toilets and bathrooms/showers throughout the home, No more than three people shared each bathroom and toilet. There is a large kitchen on the ground floor of the home and smaller kitchenettes on the upper floors. These are all used by the people living in the home when self catering. Since the last inspection good work has taken place to refurbish the kitchenettes with modern units and kitchen equipment. Two people at the home confirmed that all the equipment in the kitchenettes was in good working order. The laundry was appropriately equipped and was accessible to the people living in the home. People are encouraged to do their laundry on specific days so that everyone does not try to use the machines at the same time. The home was generally clean. The people living in the home took responsibility for keeping their own rooms clean and tidy with the support of staff. The home employed a domestic assistant several days a week to clean the communal areas. The garden at the rear of the house was well maintained and provides a nice area for people to relax in during the summer months. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are properly recruited and vetted to ensure that people are supported by suitable staff. Staff are provided with access to qualifications to help equip them to carry out their work. There is scope for updating food hygiene training to ensure that safe food handling practices are maintained. EVIDENCE: The assistant manager explained that there are typically two people on each shift and three on some days. This was verified by staff and entries in recent rotas. The manager explained that there has been one new member of staff recruited and another worker has transferred from another of the organisation’s homes to provide cover for long term sickness. Overall the staff team has remained quite stable supporting consistency of support for people at the home. The people at the home confirmed that they have no problems in accessing support from staff and confirmed that staff are friendly, supportive and helpful. The staff team includes mainly female staff but there are also two male staff. This means that the people at the home benefit from support and conversation from staff of both genders. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 24 Two staff at the home confirmed that they are provided with access to training to achieve National Vocational Qualifications so they are better equipped to carry out their work. Training information provided by the assistant manager indicates that with the exception of one new member of staff all have now achieved National Vocational Qualifications at level two or three. Most staff have also previously completed mental health awareness and “voices” training providing an insight into the needs of people with mental illness. The assistant manager also explained that all staff are currently undertaking fire safety training to support safe practices in the event of a fire. Similarly all staff are currently completing medication training workbooks to update their knowledge. 6 staff were provided with first aid training at the start of this year and other staff have reportedly completed this training previously. The training records indicate that three staff completed food hygiene training in the last year but it has now been three years or more since most other staff have done this training. The assistant manager said that training would be arranged for other staff to ensure there knowledge is updated. This is important so that staff are equipped to support good food hygiene practices in the home. As it has been four years since most staff had adult abuse training, the assistant manager said that she would be seeking training updates for staff. A member of staff said she had seen the training course booklet that was available in the office of the home and is allowed to apply for relevant courses. The manager said that a number of staff would be attending these courses, including drug awareness and epilepsy training that is planned to take place shortly. The recruitment files of a new member of staff was checked. The file contained evidence to confirm that proper recruitment and vetting procedures had been followed, to ensure that people are supported by suitable staff. The vetting checks include taking up identification checks, references and a Criminal Record Bureau check. The operations manager for the service explained that job histories are checked so that any gaps in employment can be investigated and properly explained by staff applying for posts with the organisation. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good systems are in place for involving people so that they can exercise some control over the management of the home. Shortfalls in care plans could compromise the quality of the care and support provided at the home. EVIDENCE: The assistant manager is currently carrying out the day-to-day management of the home whilst the Registered Manager is on a temporary secondment within the organisation. The assistant manager explained that she holds the National Vocation Qualification level 3, in care and is currently completing the step up to management qualification to help her in her role. She said that the Registered Manager visits the home each week to provide support, as does the operations manager. This was verified in a telephone conversation with the Registered Manager. The Registered Manager agreed to send a letter to us Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 26 confirming the planned length of the secondment and the management arrangements at the home during this period. Birmingham MIND has various ways of involving people in the running of their services. Regular meetings are chaired and run by the people at the home. Comments by people who attend the meetings indicate they feel their ideas are listened to and the meetings are purposeful. One of the people the home is involved in staff interviews to represent the interests of the people that live there when new staff are being recruited. Another person at the home attends an organisational sub group, which monitors the work of the residential services run by MIND. Committee members of the organisation visit the home on a regular basis to monitor the work of the home. The notes of these meetings confirm that the visits include checking that people are happy and picking up any issues in the running of the home. Staff confirmed that systems are in place for checking the home’s money and medication during the shift handover periods, when staff going off duty and those arriving meet together to update on significant events at the home. Staff confirmed that they receive regular supervision and have good access to managers when necessary. A staff member’s supervision records were checked. The records indicate that supervision is used purposefully, e.g. to consider people’s workloads and training issues. A sample examination of recent fire equipment test records confirmed that fire alarms and lights are being routinely tested and that the fire safety equipment is being properly maintained. People at the home confirmed that they have had fire drills and that they know the procedure for evacuating the building in the event of a fire. This was verified by entries in the fire safety log. Hot water monitoring records indicate that the hot water is being kept at a safe and comfortable temperature for service users. Electrical test records confirm that electrical equipment is being regularly checked and inspected as required As previously noted there are significant shortfalls in some care plans and risk assessments, which could lead to people not receiving the correct support they need and could compromise safe practices. The assistant manager has agreed to address this matter. The Registered Manager has been informed of this shortfall so that he can monitor the development of this information. Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 27 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 2 2 x 3 3 4 x 5 3 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 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 3 x Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The review of the Statement of Purpose and service user guide should be completed promptly so that new people considering a move to the home have up to date information to help them make a decision. All the people living in the home should have up to date care plans that detail how all their support needs are to be met by staff. This will ensure the people living in the home receive person centred care in a way that suits them. Risk assessments should contain more detailed strategies for managing the risks so that everyone living and working at the home are supported to remain safe. This will ensure that the people living in the home are not exposed to any unnecessary risks. There should be individual written guidelines for staff to follow for any PRN medication being administered to the people. This will ensure they receive their medication when it is needed. DS0000016858.V364842.R01.S.doc Version 5.2 Page 29 2 YA6 3 YA9 4 YA20 Pershore Road (807) 5 6 7 YA24 YA35 YA37 The staircases should be redecorated to ensure the standards in the home are acceptable to the people living there. Proceed with plans to provide staff with food hygiene training updates to support safe practices. Proceed with plans to write a letter to us detailing the planned length of the Residential Managers job secondment and confirming the temporary management arrangements at the home during this period Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Pershore Road (807) DS0000016858.V364842.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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