Inspection on 19/12/05 for 88 Church Lane

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

88 Church Lane 13/09/07

88 Church Lane 04/12/06

88 Church Lane 03/12/04

88 Church Lane 14/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Church Lane, 88 Handsworth Wood Birmingham B20 Lead Inspector Donna Ahern Unannounced Inspection 19th December 2005 13:25 Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church Lane, 88 Address Handsworth Wood Birmingham B20 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) 0121 687 1564 0121 687 1656 Sense West Paul Jones Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager to achieve NVQ Level 4 or equivalent by March 2005 Registration for 5 younger adults (under 65 years of age), categories learning disability and sensory impairment April 2005 Date of last inspection Brief Description of the Service: 88 Church Lane is a large spacious house that has been adapted to meet the needs of people with visual and hearing impairment and associated learning Disabilities. The home is located in the Handsworth Wood area of Birmingham. Sense are the homeowners and the care providers. The home is registered to provide care and accommodation for five adults. The accommodation comprises of a large communal lounge a separate dining room and large kitchen. There is an additional quiet lounge on the first floor and a sensory room. All five bedrooms have ensuite bathrooms. One bedroom is on the ground floor and four are on the first floor. An office and staff sleep in facilities is located on the second floor. There is off street parking at the front of the house. The home has a large rear garden with a decked terrace and steps leading to a lower grass area. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over an afternoon. Conversations with the deaf/blind people were limited due to their complex needs and limited verbal communication abilities. However, the inspector was able to have discussions with one of the people who live at 88 Church Lane and spent time with all four deaf/blind people observing care practices, interactions and support from staff. A partial tour of the building was made. Care plans; risk assessments, accident records and fire records were inspected. Staff training and recruitment files were not examined as no manager was on duty to give access to this information, which is held securely. The inspector had the opportunity to talk to five support workers. This report should be read in conjunction with the report of the visit of 28th April 2005. What the service does well: What has improved since the last inspection? Improvement had been made to how staff record the persons response to the range of activities on the daily record sheets, so that the staff team can monitor that the person is enjoying and or benefiting from the activity. The log of complaints had been developed so that action taken and outcomes could be tracked. Staff said the management style of the home had improved and that “things now get done” and “sorted out” and that the acting manager “is well organised”. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 6 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. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: There have been no recent admissions to the home. Admission documentation has been assessed at previous inspections. The standard was not assessed. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Risk assessments required some further development to enable the resident’s safe participation in activities. Care plans required review so that they reflect resident’s current needs. EVIDENCE: Individual plans of care are available for each resident. Two of the care plans were examined and found to contain detailed information regarding personal and social care, and health care needs. There was detailed information regarding the deaf/blind person’s communication needs. There was evidence of some penned in additions and changes and rewording of information. The care plans required updating and reviewing so that they are an up to date document that reflect resident’s support needs. Daily records were sampled and there was evidence of considerable improvements to the quality of the information recorded. The minutes of monthly core team minutes which are meetings involving key staff involved in supporting individual residents, were on sampled files. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 10 A number of risk assessments were in place for each person. Some of these were sampled. Further development of the risk assessments was required, so that they are clear and specific about what the risks are and the required action to be taken by staff to reduce the risks. Some of the risk assessments were repetitive and could be condensed. The home was still working on ensuring that risk assessments cross-reference to the care plan and relevant policies and procedures as raised at the previous inspection. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 11 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, 16, 17 The range of leisure and recreational activities within the local community are sometimes restricted. Residents are free to access all areas of the home. EVIDENCE: Previous inspection reports raised concern regarding the restrictions that were in place within the home to safeguard the residents. One of the people had their own staff team and was being supported separately to the other residents. At times during the day the residents could not access some of the communal areas of the home. The person was supported to move on to alternative accommodation in October 2005 and the previously reported restrictions had been removed. Residents were able to freely access all areas of their home. Part of the lunchtime routine was observed. Residents received appropriate support from care staff. Menus were looked at. There is a six-week rolling menu in place. Staff said they were due to review the menus. One of the residents was being supported with a healthy diet to reduce their weight. The inspector forwarded contact details for the learning disability dietician service for advice and support and for a referral to be made. Staff were asked about Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 12 progress on producing the menu in a pictorial format as discussed at the previous inspection. They stated that there had been some difficulties with implementing this system within the home due to the needs of one of the residents. Staff demonstrated that they were keen to explore other options. One of the residents said that they have a busy week and attend college three days a week and go out to visit friends and family. Their only concern was the lack of staff that can drive the homes transport, which they said sometimes, does have an impact on resident’s opportunities to go out. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 13 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 deaf/blind person has access to range of Health Care professionals so that their health care needs are assessed. Some improvements was required to the outcome of appointments so that their health needs are fully monitored. Some development of manual handling assessments and guidelines were required to ensure that individuals receive the appropriate support. Medication administration required attention so that resident’s safety is protected. EVIDENCE: Sampled care plans had guidelines in place on how personal care should be delivered, some updating was required. Manual handling risk assessments had been completed however as previously reported these required further development. For the individuals who required some assistance with their mobility the assessments were not specific enough about the support required by the person from staff. An Occupational Therapy assessment referral had been actioned for one person however the assessment remains outstanding. Please inform CSCI of the outcome. Residents are supported to access a range of health professionals. The care plans contained details of appointments and there outcomes. Health Action Plans have been implemented for all residents and were generally well utilised documents. One of the sampled plans had some shortfalls in the recording of Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 14 heath outcomes. Attention is required to the recording so that information is clearly documented in the right section. Medication is stored in a locked cupboard in the hallway. Amounts of incoming medication must be entered on the Medication Record sheet so that the medication can be audited. The use of paracetamol for one residents required review. The amount administered did not balance with the amount remaining there was a significant shortfall. It was unclear how many paracetamol were administered at a given time. The manager must implement a system for the regular audits of medication. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 15 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 Residents are listened to and adult protection procedures are implemented when required. CSCI must be informed of the outcome of outstanding investigations. EVIDENCE: The organisation has comprehensive complaint procedures and adult protection procedures these were not assessed at this inspection. The complaint logged indicated that some complaints remained under investigation. CSCI have received one complaint about the home since the previous inspection, this was passed back to the provider to investigate. Part of the complaint was about staff practice and this was upheld and appropriate action was taken by the organisation prior to the anonymous complainant contacting CSCI. One of the elements of the complaint was still under investigation. CSCI must be informed of the outcome. One resident said that if they are not happy about something they could talk to staff who will try and sort things out. The acting manager had appropriately made an adult protection referral regarding an incident that had occurred in the home. The matter was still under investigation at the time of compiling this report. The acting manager had agreed to keep CSCI informed of developments. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 16 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, 30 The home is spacious and offers residents a good choice of communal and personal space. Some maintenance matters required attention so that residents are provided with a comfortable and safe environment. EVIDENCE: The home is in keeping with the local community and was not distinguishable as a care home. 88 Church Lane is a large traditional house that has been adapted to meet the needs of the deaf/blind person. It is comfortable, homely and very spacious. It has a range of communal rooms including two lounges on the ground floor and two on the first floor. Only a partial inspection of the physical standards was undertaken. The home is comfortable and on the whole is well maintained. Carpets required cleaning throughout the ground floor. In one of the resident’s bedroom their Curtains required hanging, a socket required securing and their personal doorbell required repairing. The home has one bedroom on the ground floor, which would be accessible to a person with limited mobility. All other bedrooms are on the first floor and Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 17 would not be accessible to a person with limited mobility, the home does not have a lift. The present environment does not pose any difficulties for the current residents. However, following an assessment by an independent mobility assessor, a handrail had been installed in one of the ensuite bathrooms to help with the person’s mobility. The manager had also made a referral to the Occupational Therapist so that their needs can be fully assessed. Please inform CSCI of the outcome. This remains outstanding from the previous inspection. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 18 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, 35 Staff training must be actioned in mandatory areas so that staff have the required skills and knowledge to do their job. Interactions between residents and staff were positive. EVIDENCE: Staffing levels had been reduced since one of the residents moved to another home and occupancy levels have been reduced to four. The rota indicated that there are two staff on each shift (07.30-15.00) (14.00-22.00) and one person working across the day to provide additional support (9.00-17.00). At night two staff are on duty one undertakes a sleep in shift to provide on call support if needed. The previous inspection raised concern about the balance of sense employed staff and agency staff on duty. Of the five staff on duty at this inspection three were permanent staff and two were long standing agency staff. The inspector spoke to all five staff members four on a one to one basis. All staff demonstrated a good knowledge of resident’s needs and the homes procedures. Observations of staff interactions with residents throughout the inspection were positive. Staff were friendly, helpful and supportive to residents. One resident said that on the whole staff were very good and the new staff were settling in very well. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 19 The inspector was unable to assess staff personnel files, as there were no members of the management team on duty to give access to this information. Staff spoken to said that they received regular supervision and support from the acting manager. Staff stated that they required some updates in mandatory training. Again this information was not accessible. A copy of the training plan and Matrix must be forwarded to CSCI so that training needs can be fully assessed. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42, 43 The management arrangements for the home must be resolved so that residents can benefit from a permanent manager. EVIDENCE: The registered manager has been seconded to a position within the organisation. The deputy manager was acting manager but was not on duty at the time of the inspection. Staff spoken to made extremely positive comments about the temporary manager. Staff said that “things now get done” and “sorted out” and that the acting manager “is well organised”. Interim management arrangements have been in place for three months. The organisations must notify CSCI of what its intentions are for the long term management of the home. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 21 The Work Place Fire Risk assessment required review. Clarification that the matters raised by West Midland Fire Service in May 2005 have been resolved was required and must be put in writing to CSCI. The organisation had undertaken regulation 26 visits as required. Reports have been forwarded to CSCI on a monthly basis. The reports are comprehensive and include consultation with the deaf/blind person. One of the residents confirmed that the service manager speaks to them on a regular basis and asks them about their views of the home. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X X X X 2 3 Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA9 Regulation 15 (1) (2) 13(4)(a, b, c) Requirement Care plans required review. Further development of risk assessments was required, so that they are clear and specific about the risks and the required action to be taken by staff to reduce the risks. (Previous requirement 30/06/05) Manual handling risk assessments required further development. CSCI must be informed of the outcome of the Occupational Therapy assessment and the action to be taken by the manager (Previous requirement 31/08/05) Health recording must be improved so that outcomes and follow up can be tracked. Medication must be audited. Attention was required to the administration and recording of medication. The outcome of complaints still under investigation must be notified to CSCI. Carpets required cleaning on the ground floor. The front drive of the garden DS0000030401.V274792.R01.S.doc Timescale for action 19/03/06 19/02/06 3. 4. YA18 YA18 13 (5) 14 (2) 13 (5) 30/06/05 28/02/06 5 6 YA19 YA20 12 (1) a 13 (2) 31/12/05 20/12/05 7. 8. 9. YA22 YA24 YA24 22 (3)(8) 23 (2) (d) 23 (2) (b) 19/02/06 31/01/06 31/01/06 Page 24 Church Lane, 88 Version 5.1 10 YA24 23 (2) b 11. 12. YA33 YA34 18 (1) (a) 7,9,19 13. YA35 18 (1) c 14 15 YA35 YA37 18 (1) c 8 (1) 16 17 YA42 YA42 23 (4) (a, b c) 23 (4) required repair as it is uneven and presents as a potential hazard. (Previous requirement carried over 3/2/05) In a residents bedroom their Curtains required hanging, a socket required securing and their personal doorbell required repairing. The home must recruit to vacant posts. The required records in relation to the employment of staff must be available in the home. (Previous requirement 31/1/05) NOT ASSESSED requirement carried over to this inspection Staff training records must be up to date so that they are a current and accurate record of completed training. The record of training must include duration, date and training body. NOT ASSESSED requirement carried over to this inspection. A Training plan and matrix is required and must be forwarded to CSCI. The organisations must notify CSCI of what its intentions are for the long-term management of the home. Workplace Fire risk assessment required review. The provide must confirm that all matters raised in The West Midland Fire report dated May 2005 have been actioned. 31/01/06 31/03/06 31/01/06 31/01/06 19/02/06 19/02/06 19/02/06 19/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000030401.V274792.R01.S.doc Version 5.1 Page 25 Church Lane, 88 1. Standard YA38 Review location of the office. Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 26 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 Church Lane, 88 DS0000030401.V274792.R01.S.doc Version 5.1 Page 27 - 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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