Inspection on 21/06/07 for 807 Pershore Road

This inspection was carried out on 21st June 2007.

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

Other inspections for this house

807 Pershore Road 19/05/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Pershore Road (807) Selly Park Birmingham West Midlands B29 7LR Lead Inspector Brenda O’Neill Key Unannounced Inspection 21st June 2007 09:30 Pershore Road (807) DS0000016858.V337942.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.V337942.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.V337942.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 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.V337942.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. 4th October 2005 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 fees at the home were £552.00 per week. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out over one day in June 2007. During this visit a tour of the premises was made, the files for two of the people living in the home and staff training records were sampled as well as other care and health and safety documents. The inspector spoke with five of the people living in the home and four staff. The day before the inspection the manager had returned a completed annual quality assurance assessment (AQAA) to the Commission that gave some additional information about the home. This included information on where the service had improved and what they could further improve. The home had not logged any complaints since the last inspection and none had been raised with the Commission. What the service does well: The pre admission assessment process for people being admitted to the home was good. Individuals were fully involved in the assessment process and they could visit the home as often as was felt necessary prior to being admitted to the home. The staff spoken with were very knowledgeable about how to recognise when the mental health of the people living in the home was relapsing and could clearly describe the type of behaviour that may suggest this. The daily notes made by staff were very detailed in relation to individuals’ mental health where there was any deterioration and it was evident this was closely monitored. The interactions between staff and the people living in the home were very positive and the individuals spoken with were very satisfied with the support they received from the staff. Information received prior to the inspection from the manager stated that 90 of the staff at the home were qualified to NVQ level 3 which is to be commended. The people living in the home made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. The people living in the home were encouraged and supported by staff to develop skills in cooking, laundry, cleaning and how to budget their money in preparation for their move to more independent living. A variety of opportunities for college courses, day centres, and days out were made available for the people living in the home. Staff enabled them to undertake their preferred activities wherever possible. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 6 Contact with family and friends was encouraged and supported by staff. All the people living in the home self catered the majority of the time. Each person was given a self catering budget but they did not have to purchase every day items from this, for example, bread and milk as these were provided by the home. The people living in the home were encouraged and supported to administer their own medication in preparation for moving to more independent living. The people living in the home were comfortable in the presence of the staff and were able to raise any queries or issues. One of the people spoken with confirmed that if he raised anything with staff they did act on it. The home was very spacious and generally comfortable and the people living in the home that were spoken with were satisfied with their bedrooms. What has improved since the last inspection? What they could do better: To evidence that the information available to people who wanted to move into the home was up to date copies of the Statement of purpose and service user guide needed to be forwarded to the Commission. All the people living in the home needed to have care plans in place that they had been consulted about to ensure they received person centred support in way that suited them. To ensure the people living in the home were not exposed to any unnecessary risks there needed to be comprehensive risk assessments in place for any identified risks that included strategies for managing the risks. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 7 Risk assessments needed to be fully developed and implemented to identify the mental health needs of the people living in the home and must include early warning indicators of relapse and inform staff of what they must do. To ensure the people living in the home received their medication when required there needed to be individual written guidelines for staff to follow when medication had been prescribed as PRN (as and when necessary). Evidence needed to be forwarded to the Commission that staff had undertaken all the necessary training to undertake their roles. 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.V337942.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.V337942.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 4 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information available for people wanting to use the service did not reflect the current service offered in the home. The arrangements for assessments of prospective users of the service are good and take into account the individual’s aims and aspirations. EVIDENCE: There had been some changes made to the service being offered at the home since the last inspection. 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. At the time of the inspection the manager was not on duty. The statement of purpose for the home could not be found and the service user guide seen was not up to date. This was discussed with the manager after the inspection and he stated both had been updated and copies would be sent to the Commission. The files for two people admitted to the home since the last inspection were sampled. Both files included evidence that assessments had been undertaken Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 10 prior to the individuals being admitted to the home both by staff at the home and the relevant professionals. Both the individuals were spoken with and they confirmed they had visited the home more than once prior to admission and that they had also been to look at another home that offered the same service. No written evidence of the pre admission visits were seen. It was recommended that some records of pre admission visits were kept as evidence of how the stays had gone and if any issues arose that needed to be addressed. Both files included licence agreements that detailed the terms and conditions of living in the home. Pershore Road (807) DS0000016858.V337942.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 poor. This judgement has been made using available evidence including a visit to this service. Current care plans detailing the changing needs, personal goals and the staff support required were not in place for all the people living in the home. Individual risk assessments needed to be further developed to ensure all risks were identified and minimised. The people living in the home made decisions about their lives on an ongoing basis. EVIDENCE: The files for two of the people living in the home were sampled. Care plans at the home were entitled Essential Lifestyle Plans (ELPs). Neither of the files sampled included a current ELP. One did include an initial ELP when the person had moved into the home which included some information about the support the individual required, their family, faith/culture, financial issues, education and training and safety/risk issues. At the time of the inspection this information was over a year old. There was also a completed self-assessment form. This included what the individual wanted to achieve, what had helped them in the past, what skills they thought they had and what they wanted to Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 12 improve. The other file sampled did not have either an ELP or a completed self-assessment. Due to the lack of current ELPs it could not be determined at what stage the individuals were in relation to their rehabilitation or what their short term goals were to help them reach the stage where they were able to move out of the home. One of the individuals had been in hospital for some time. There was no evidence that since the persons return to the home they had been involved in any discussion as to what the next stages in their rehabilitation were to be. Prior to the person being admitted to hospital some monthly evaluations had been undertaken with the person concerned to assess the progress they were making towards their goals. These also highlighted where issues had been raised about the deterioration in the individual’s mental health. The evaluations also included an action plan for follow up during the next month. Monthly evaluations had also been undertaken with the other person being case tracked and these were documented on the individual’s files. As there was no ELP it was difficult to know what was being evaluated and the evaluations did not always follow on from one month to the next. This again made it very difficult to determine what the individual was aiming for at any particular time. For example, one stated ‘remind of weekly planner’ but this was not seen and it was not clear what this included. Both files did include some risk assessments for issues such as aggression and violence, self neglect, exploitation and self harm. These included any triggers, early warning signs and any action to be taken. However in most cases they were very brief, some were not fully completed, dated or signed. One that was dated in November 2006 stated to review in three months but there was no evidence this had been completed. It was evident from the daily records that the two individuals concerned were exposed to other risks, for example, one could dress very inappropriately which could have made them vulnerable in the home, another had had some restrictions on them leaving the home until very recently but there was no management plan informing staff what they were to do should the person leave the home. The staff spoken with were very knowledgeable about how to recognise when the mental health of the people living in the home was relapsing and could clearly describe the type of behaviour that may suggest this. It was of concern that there were no written management plans in place that identified how staff would recognise when any of the individuals’ mental health was deteriorating and what they should do about it as the home used bank staff and on rare occasions agency staff who would not know the people living in the home as well as the permanent staff. The people living in the home made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. They were fully involved in the assessment process prior to moving into the home and Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 13 their monthly evaluations once resident at the home. They made decisions on a daily basis about what courses they attended, how they spent their leisure time, what they had to eat and when and if they saw their family and friends. All the people living in the home managed their own finances and could have staff support for this if it was required. Restrictions on the movements of the people living in the home were only put in place when it had been deemed unsafe for them and there had been full consultation with all the professionals concerned. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 14 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. The people living in the home were supported to have an independent life style which the home encouraged and supported them to achieve. Their rights and responsibilities were recognised in their every day lives. EVIDENCE: There was ample evidence that the people living in the home followed an individual lifestyle and that opportunities for personal development were encouraged. The whole aim of the home was to support and encourage people to move on to more independent living. The people living in the home were at various stages in this process. For example, one of the individuals spoken with had moved to the home two weeks before the inspection and spoke to the inspector about his wish to move to a flat but knew he was not ready for this yet and that was why he was at the home. Two other individuals went out to look at some supported housing on the day of the inspection to see if they Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 15 liked it and thought they would like to move there. One was spoken with when he returned and had mixed feelings about the accommodation. The people living in the home were encouraged and supported by staff to develop skills in cooking, laundry, cleaning and how to budget their money in preparation for their move to more independent living. A variety of opportunities for college courses, day centres, and days out were made available for the people living in the home. Staff enabled them to undertake their preferred activities wherever possible. Daily notes and conversations with the people living in the home evidenced they pursue their own activities, for example, one individual spoke about going out to concerts and having their own musical instrument. Some of the people in the home preferred to spend a lot of time in their rooms listening to music or watching DVDs. There was some evidence on in house activities such as card games and gardening. Information received prior to the inspection from the manager stated the home are to employ another staff member to enable access to more activities. During the course of the inspection the people living in the home were seen to come and go from the home as they wished. They accessed the facilities in the local community as they wished, for example, shops, pubs and doctors. Staff support was available to support people when going out into the community if required. Contact with family and friends was encouraged and supported by staff. During the course of the inspection one of the people living in the home had two visitors and both were made welcome. One of the people living in the home spoke of going to stay with his family on a regular basis another was on holiday with friends. There was also a telephone for the use of the people living in the home so they were able to keep in contact with family and friends. The rights and responsibilities of the people living in the home were recognised on a daily basis. Individuals spoken with told the inspector there were no rules really but you were asked not to smoke in certain areas of the home. All those spoken with confirmed they had keys to their bedrooms and the front door and that staff did not enter their rooms without permission. People living in the home were taking responsibility for cleaning their own rooms, doing their own laundry and cooking most of their meals but if they needed support from staff they asked and it was given. All those living in the home at the time of the inspection handled their own money but again systems were in place to help anyone with budgeting where necessary. At the time of the last inspection the people living in the home could self cater if they wished. Since the change to the service all the people living in the home were self catering for the vast majority of their meals. Sunday lunch was cooked for them and Saturday was usually a take away meal. At all other Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 16 times the people living in the home shopped and cooked for themselves with staff support where necessary. Some of the individuals used the main kitchens others used the smaller kitchens located on each floor of the home. The inspector saw people preparing and cooking cultural dishes of their choosing, going out shopping for provisions and preparing snacks. Each person was given a self catering budget but they did not have to purchase every day items from this, for example, bread and milk as these were provided by the home. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 17 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. Relapse management plans in relation to people’s mental health needed to be in place to ensure all staff working at the home could easily identify any issues. EVIDENCE: The people living at the home were independent in terms of personal care and only needed prompting by staff. There was only one female living at the home the inspector spoke with her and she indicated she did not feel isolated as she had good relationships with the staff the majority of who were female. The appearances of the people appropriately reflected their differences in personalities and age groups. Staff spoke to the inspector about encouraging the people living in the home to pursue a healthy lifestyle through their diet and some exercise but they also acknowledged that this could be difficult at times due to the choices made by the individuals. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 18 Files sampled evidenced that people living in the home were registered with a local G.P. and visited when necessary. General health checks at dentists and opticians and so on were also available as necessary. The daily notes made by staff were very detailed in relation to individuals’ mental health where there was any deterioration and it was evident this was closely monitored. The appropriate professional help from specialist mental health teams was sought as necessary, for example, the home treatment teams. At the time of the inspection one of the people living in the home was in hospital due to deterioration in their mental health and another was waiting for admission, at his request as he knew he was unwell. It was clear from observations made during the inspection and the daily records that the mental health of one of the individuals in the home was giving cause for concern. As stated previously it was of concern that there were no relapse management plans in place, on the files sampled, for staff to refer to that indicated the signs of relapse and how best to manage these as the home used bank staff who would not know the individuals as well as permanent staff. The medication system in the home was generally well managed. The people living in the home were at different stages in the process of self administering their medication. One was totally self administering, another had his medication on a daily basis to administer and others were supported by staff to fill their weekly cassettes and then went to staff to administer their medication. Throughout the course of the inspection the people living in the home were observed asking for their medication and staff reminded others. At the front of the medication file there were instructions for staff as to what stage each individual was at and what support was to be offered. There was evidence of assessments on file for those self administering. One minor discrepancy was found when auditing the medication where the wrong balance had been carried forward. A requirement was made following the last inspection in relation to written protocols not being in place for the administration of PRN (as and when necessary) medication this remained outstanding at the time of this inspection. Pershore Road (807) DS0000016858.V337942.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. The views of the people living in the home are listened to and acted on. The policies and procedures on site and the training staff had received ensured the people living in the home were safeguarded. EVIDENCE: The information received from the manager prior to the inspection stated that no complaints had been lodged at the home since the last inspection. No complaints or concerns about the service had been lodged with the Commission. The people living in the home were comfortable in the presence of the staff and were able to raise any queries or issues. One of the people spoken with confirmed that if he raised anything with staff they did act on it. According to the AQAA document the home also had an independent mentor/representative for the home and that one of the aims for next year was to try and widen the range of independent support and advocacy available to the people living in the home. The home had adult protection procedures on site and these had been amended as required at the last inspection and they now complied with the multi agency guidelines. No adult protection issues have been raised at the home since the last inspection. At the time of the last inspection the staff working at the home had received training in adult protection issues. An up to date training matrix was not available at the time of the inspection therefore it Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 20 could not be determined if all the current staff had received training. The manager of the home was spoken with after the inspection and was to forward a training matrix to the Commission. Pershore Road (807) DS0000016858.V337942.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, 25, 27, 28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements had been made to the environment which was generally well maintained, clean and comfortable and met the needs of the people living there. 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. Since the last inspection the main kitchen had been refurbished, some new furnishings had been purchased for some of the communal areas and some redecoration had taken place. The bedrooms seen varied in size and one had ensuite facilities and a small kitchenette area. Both the occupants of the rooms seen were satisfied with their rooms and had personalised them to their choosing. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 22 There were adequate numbers of toilets and bathrooms/showers throughout the home, No more than three people shared each bathroom and toilet. There was ample communal space for all residents with designated dining and smoking areas. The dining room also housed a pool table and telephone for the use of the people living in the home. The furnishings in the smoking lounge and the carpet in both lounges were in need of cleaning. Both lounges were equipped with televisions and music systems. It was noted that the staircases in the home were in need of redecoration. The garden to the rear of the home was adequately maintained. There was a large kitchen on the ground floor of the home and smaller kitchenettes on the upper floors. These were all used by the people living in the home when self catering. There were several fridges and freezers in the home. It was noted that the seal on one of the freezers in the main kitchen was badly split and this needed to be addressed. Also some of the fridges and freezers needed to be cleaned. The temperatures of the fridges and freezers were being recorded on a daily basis however some of these indicated that some of the fridges were running at excessively high temperatures. The laundry was appropriately equipped and was accessible to the people living in the home. Staff tried to encourage the people living in the home to do their laundry on specific days so that everyone was not trying 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 two days a week to clean the communal areas. Pershore Road (807) DS0000016858.V337942.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home were knowledgeable about the needs of the people living there. There was no evidence available to determine if staff received all the necessary training to equip them with the necessary skills and knowledge to carry out their roles. EVIDENCE: Discussions with staff on duty evidenced they had a clear understanding of the needs of the people living in the home and the support they needed. The interactions between staff and the people living in the home were very positive and the individuals spoken with were very satisfied with the support they received from the staff. The manager was not on duty on the day of the inspection. The staff on duty handled the inspection with confidence and were very helpful. There had been no new staff appointed at the home therefore recruitment procedures were not assessed at this inspection however it is known that MIND had robust recruitment procedures and there were no outstanding Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 24 requirements in this area. Although no new staff had been recruited there had been some staff changes and staff had moved to the home from other services run by MIND. Information received prior to the inspection from the manager stated that 90 of the staff at the home were qualified to NVQ level 3 which is to be commended. It was not possible to determine what ongoing training staff had had as the individual training records seen were not up to date. This was discussed with the manager during feed back after the inspection. He stated he had a training matrix for the staff team and he would forward a copy to the Commission. This had not been received at the time of writing this report. There was one requirement made following the last inspection in relation to induction records for new staff being kept on site. As no new staff had been recruited it was not possible to assess this. This requirement has been removed as induction training will be assessed when any new staff are recruited. Pershore Road (807) DS0000016858.V337942.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, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. Some issues needed to be addressed to ensure the people living in the home were fully safeguarded. EVIDENCE: The registered manager has a lot of experience of supporting people with mental health needs and the running of a residential home. He was not on duty at the time of the inspection however the inspector did speak to him briefly on the telephone at the start of the inspection and at some length the day after to feed back the findings of the inspection. He was made aware of the issues that needed to be addressed in particular the lack of ELPs and comprehensive risk assessments for the people living in the home. Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 26 The staff on duty at the time of the inspection managed the inspection with confidence, were helpful and clearly knew the needs of the people living in the home. Relationships between the people living in the home and staff were good. They were very positive in their comments about the manager of the home. There was no doubt the home was run in the best interests of the people living there and they were encouraged as much as possible to take part in the running of the home, for example, they could take part in staff recruitment and staff training if they wished. There were regular meetings with the people living in the home where a variety of topics were discussed. Other internal quality audits were also undertaken in relation to such things as health and safety and medication. MIND does have a quality monitoring system in place that involved internal audits being undertaken and an annual development plan for the home was produced as a result. During the feedback to the manager he stated that a new system was being developed but that the home did have a development plan for this year. A copy of this plan was to be forwarded to the Commission. Health and safety at the home were well managed. Only minor issues were raised in relation to the fridges in the home. The information received on the AQAA detailed that all the equipment in the home had been serviced as required. Staff confirmed they had had up to date fire training. It was confirmed with the manager that he had pursued the outstanding requirement from the fire officer in relation to having smoke detection in the loft space. He had been advised this was only needed if the area was to be used for storage. He also confirmed that the water system had been checked for the prevention of legionella. Pershore Road (807) DS0000016858.V337942.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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 2 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 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 2 2 X 2 3 3 X X 3 X Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement All the people living in the home must have up to date care plans that detail how all their support needs are to be met by staff. There must be evidence that the people living in the home have been consulted about their care plans. This will ensure the people living in the home receive person centred care in a way that suits them. 13(4)(b)(c) There must be comprehensive 31/07/07 risk assessments in place for any identified risks that include strategies for managing the risks. This will ensure that the people living in the home are not exposed to any unnecessary risks. Risk assessments must be fully developed and implemented to identify the mental health needs of the people living in the home and must include early warning indicators of relapse and inform DS0000016858.V337942.R01.S.doc Timescale for action 31/07/07 2. YA9 3. YA9 YA19 13(4)(c) 31/07/07 Pershore Road (807) Version 5.2 Page 29 staff of what they must do. This will ensure the people living in the home are safeguarded There must be individual written 31/07/07 guidelines for staff to follow for any PRN medication being administered to the people living in the home. (Previous time scale of 01/11/05 not met) This will ensure the people living in the home receive their medication when required. Te split seal on the fridge must 31/07/07 be replaced. Fridges and freezers must be kept clean. The excessively high temperatures of the fridges must be explored to ensure the fridges are working efficiently. This will ensure the people living in the home are not exposed to any risks from unsafe food storage. Evidence must be forwarded to 31/07/07 the Commission that staff have undertaken all the necessary training to fulfil their roles. This will evidence that staff have all the necessary skills and knowledge to support the people living in the home. 4. YA20 13(2) 5. YA30 13(3) 6. YA35 18(1)(c) Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 30 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 Copies of the updated statement of purpose and service user guide must be forwarded to the Commission. This will provide evidence to the Commission that the information available to people who want to use the service is up to date. It is recommended that some records of pre admission visits are kept as evidence of how the stays had gone and if any issues arose that needed to be addressed. The soiled furnishings and carpets in the lounges should be cleaned and the staircases redecorated to ensure the standards in the home are acceptable to the people living there. A copy of the development plan for the home should be forwarded to the Commission. 2. 3. YA4 YA28 4. YA39 Pershore Road (807) DS0000016858.V337942.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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