Inspection on 04/12/06 for 88 Church Lane

This inspection was carried out on 4th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

88 Church Lane 13/09/07

88 Church Lane 19/12/05

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 2ES Lead Inspector Peter Dawson Key Unannounced Inspection 4th December 2006 09:30 Church Lane, 88 DS0000030401.V322082.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 Church Lane, 88 DS0000030401.V322082.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. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Lane, 88 Address Handsworth Wood Birmingham B20 2ES 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 554 7710/8858 F/P 0121 554 7710 churchlane@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Christine Hannah-Smith Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration for 5 younger adults (under 65 years of age), categories learning disability and sensory impairment 19th December 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.V322082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out by one inspector on one day from 10.00 am – 5.30 pm. The home provides a service to five people in the age range 36 – 49 years. Four of the residents have severe hearing and sight impairments and very limited or no speech. One resident leads a more independent lifestyle with a lower level of dependency. Fees at Church Lane are defined in the pre-inspection questionnaire as between £83,590 and £99,248 per annum. A pre-inspection questionnaire was completed by the Manager and sent to CSCI prior to the inspection. This provides a basis of information contained in this report. Four written feedback forms were received prior to the inspection one form a resident, two from relatives and one from a Consultant Psychiatrist. All areas of the home were inspected including bedrooms, escorted by residents where possible. Care plans, risk assessments, medication records, staffing rotas, fire records and other documents were seen relating to the inspection process. All five residents were seen and time spent observing and where possible interacting with them. One resident was able to give an account of his life at Church Lane and talked about the many activities he is involved in. He commented about daily routines and staff care. He has been resident at Church Lane for 3 years, says he is happy there and comments positively about the commitment of staff. He also provided a written feedback directly to the Commission. He also enabled a telephone conversation between the inspector and his mother on his mobile telephone. She confirmed that the placement was successful and that her son was leading a full and purposeful life at Church Lane. She had no complaints whatsoever and totally happy with the care provided. Two other relatives indicated similar satisfaction with care and included the comments “My daughter is well looked after, on her home visits she does seem quite happy. The management and staff have been helpful and informative on all aspects of her care. Meetings are carried out well and her room and personal items are good”. Another relative states “My son has been with Sense for 20 years, he is well looked after and happy. I have always been consulted about everything. He is happy and staff are very caring towards him” The Manager and Deputy were not on duty but all members of staff were spoken with at some length. All were keen to be involved in the inspection process and made a very positive contribution to the inspection. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There have been very significant improvements to the environment. With the exception of the kitchen – the whole of the ground floor area has been re-carpeted or vinyl flooring has been fitted. Areas include the reception hallway, dining room and large lounge area. This has improved the presentation of the home considerably. The office has been relocated from the second floor to the ground floor, it is small but adequately accessed and equipped. It is now centred on the living areas giving easy access for residents and allowing closer monitoring of the service. There has been improvement in recording health care issues, allowing closer monitoring of outcomes. The front drive of the garden area has been repaired and is now safe. Attention required to curtains, sockets and personal doorbells in residents bedrooms has been actioned. Staff recruitment and numbers have improved with new staff transferred from another home. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 7 Training records have improved and there is now a staff training matrix for easier indentification of training needs. A new Registered Manager has been appointed. The Fire Risk assessment has been updated. Matters requiring action identified by the Fire Officers reports of May 2005 and August 2006 have been satisfactorily addressed. 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 Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 9 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.V322082.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information concerning the service is readily available. Introductions to the home had concurred with good practice. Recently admitted residents had visited several times prior to admission. EVIDENCE: There was a statement of purposes and service users guide in the home available to residents/visitors. Two new people have been admitted to the home since the last inspection. They have come from another home in the Sense Group called Dawlish, which recently closed. There had been appropriate introductions to Church Lane – both people had visited 4-5 times prior to placement visiting for half-day, meals etc. They were able to meet staff and residents and familiarise themselves with the facilities the home had to offer. Additionally staff from Church Lane visited Dawlish to shadow staff there and establish the needs and routines of the people involved. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 11 Both had a post-placement review after 6 weeks and the indications were that they were settling well. Personal information including care plans were transferred to Church Lane from Dawlish. Unfortunately some of that information needs to be updated to apply in the present setting. A requirement is made elsewhere in this report relating to that matter. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All care plans and risk assessments require urgent updating of information. The reasons for the backlog of work should be considered. EVIDENCE: Updating of care plans were needed at the time of the last inspection and a requirement was made. This is still required in relation to residents already in the home and also 2 new people admitted from another home in the same Group. Whilst care plans had been brought from the other home, they have not been adapted to relate to the new environment. An example of this was a resident who had prepared his own breakfast in the former home – this had not been followed through into Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 13 his new environment. Also appropriate mapping had not taken place – he continues to take the same (wrong) route from the dining room to the lounge area. The danger is that skills may be lost in the transition. Two requirements are therefore made in relation to this: All care plans must be updated. Care plans of new residents must be reviewed and put into place swiftly to avoid loss of skills. Risk assessments were in place and had been developed further since the last report, however they had only been reviewed once this year. It is a further requirement that risk assessments are reviewed on a monthly basis in the core team meetings. Staff reported that the person directing the care planning information and having specific responsibility also for communication and activity in the home is the Practice Development Worker (PDW) whose work covers 2 homes and therefore spends half her time at Church Lane. Discussions with staff indicated that most work on care plan revision and risk assessments are the responsibility of the PDW (previously care staff) and the limited time accounts for the backlog of work in updating care plans and risk assessments. Sense should consider at least some delegation of this work to care staff who are clearly willing to undertake it. There are 6 monthly reviews for all residents including social worker, relative, resident and staff. It was pleasing to see that a health care record had been established for all residents, containing all relevant information and in chronological form. There were also very comprehensive night profiles readily available in the office area for all night staff. These included rising/retiring times, night checks, and protocols where residents rise during the night. Resident needing to be raised for toileing at 6 a.m. is returned to bed. One person retires to bed at 12.00 but continues to get up and wander during the night, he is checked at hourly intervals and has an alarm on his bedroom door to alert staff to the fact that he is up and out of his bedroom. There is clearly some risk to this which has been reduced in the risk assessment. All are offered drinks if they wish but are encouraged to return to bed to ensure further sleep if possible. One resident needs little sleep and prefers to sit in the lounge for a part of the night – staff do not discourage this – an example of choice. Church Lane, 88 DS0000030401.V322082.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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All residents have individual activity programmes and there are many positive aspects of this. Opportunities for personal development should be considered and extended. EVIDENCE: There are 5 residents in this home with varying and complex needs. One resident has functional sight and hearing and good communication skills. He tends to be the spokesperson for the group. He has many interests and leads a busy and varied life. He attends college, goes swimming, attends workshops, goes horseriding, attends for weekly massage and external music Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 15 therapy. He attends church every Sunday and is involved in weekday church activities and entertains visitors from church. He is presently learning Braille (having deteriorating vision) has a reading (magnifying) machine in his bedroom where he likes to spend time relaxing and engaging in a busy programme of activity. He has a mobile phone, used to maximum capacity for contact with family and friends. He has been at Church Lane for 3 years where he states he is happy and engages in a lifestyle of his choice. The options for the other 4 residents are comparatively limited, having varying levels of sight, hearing and speech impairment. Individual programmes of activity are provided for them both inside and outside the home. There is a common theme of swimming, art/pottery/crafts at Sense Summit Point and Birkdale Centres. Relaxation therapy and full body massage are options for all at those centres. There is also a music therapy group where residents can play drums, electric guitar etc. at high volumes to extend their experiences and skills. Similar activities are provided at Church Lane – there is a gym on the first floor used regularly by 2 residents and a therapy room with sensory equipment where residents can achieve a level of tranquillity and relaxation – this rooms is to be further developed. On the afternoon of the inspection a music session which takes place regularly was seen – the person leading the group played the guitar and was involving all residents in a very positive way playing instruments and engaging individually with each resident. All clearly enjoying the experience. Involvement is domestic activity seems very limited. The weekly supermarket shopping is now done by a member of staff. It was reported that residents had caused some disruption there. It may be that a “weekly” shop is too much for some residents to deal with but the home should consider options of smaller food shopping involving and allowing residents some social experience and choices. Residents do not seem to be involved in food preparation. It was reported that a resident did shop and cook – purchased maybe tin of beans then cooked on toast. Further options in food preparation and more purposeful involvement of residents in those routines should be considered. As mentioned previously in this report a resident recently admitted from another home did not continue to prepare his breakfast with support as he had done in the previous placement. Risk assessments are the pre-requisite to these issues but the principle of considered balanced risk taking can be applied avoiding total restriction and gradually extending social skills. One resident has been supported by staff in a healthy eating regime to reduce weight. A positive request from her family. Following the last inspection a referral was made to the learning disability dietician for general and specific advice for that person. A special diet has been established. The inspector was concerned that on 4 days the resident had All-bran for breakfast with “limited milk” staff felt also that this was not an appealing prospect and other aspects of the menu seemed bland and uninteresting. This resident has limited sight, speech and hearing – the sense of taste and smell are clearly important. It is Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 16 recommended that the prescribed diet is further discussed with the dietician and/or possibly with a nutritional specialist. All residents require staff support and escort into the community. At the time of the last inspection there were limited numbers of staff available to drive the homes vehicles and concerns this may restrict external activity. Three additional drivers are now available – new staff having transferred from a home recently closed within the Group. Previous reports of difficulties in providing pictorial menus have been overcome – these are now available for all residents where appropriate – they can make positive choices. It was pleasing to establish that all residents have family contacts and positive involvement with them. Not all relatives are local but there are visits to the home by all parents. Two spend at least 2/3 weeks each year on holiday with relatives. Some go home for the day on a regular basis, most relatives visit regularly too. One has spend several days in London with a parent and the home provides long-distance transport in another instance for weekend stay. This involvement is very positive and available to all residents. The need for advocacy services are not required at this time. Church Lane, 88 DS0000030401.V322082.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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of health care recording have improved and are good. This can be further expanded in some areas. Some aspects of the recording on MAR sheets require improvement and regular audit of the system required. EVIDENCE: There are separate health care logs for each person. These contained good information including medication, vision and audiology assessments, weight and interventions by health care professionals. A more comprehensive assessment tool is available in a format provided by Sense called A Baseline Assessment for Vision, Hearing & Health. This had been completed in one instance seen but not in others. This document should be completed for all residents. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 18 In relation to documentation relating to health there seemed again some confusion about the role of the Practice Development Worker (mentioned earlier in this report) and her responsibility for “communication and activities” perhaps this could be interpreted for staff who appear willing to undertake some responsibility for providing and reviewing personal information but are wary of encroaching on the territory of the PDW. Specific health conditions are known and recorded. 3 residents have diagnosed heart conditions, one attends hospital for monthly tests for antibody infusion. Some residents have ongoing appointments with psychiatrists. A Consultant Psychiatrist had provided written feedback to the Commission stating that he was satisfied with the overall care and co-operation of staff at Church Lane. The usual range of health care services are accessed in the community and services offered by the learning disability specialists. The service reported under Regulation 37 four incidents of challenging behaviours since the last inspection. These were discussed and reviewed with staff. They had been adequately recorded and dealt with in an appropriate and professional way and were mild forms of reactive behaviour. Diversionary tactics had been deployed and the situations diffused. Staff have all received training in this area of work. The medication system was inspected. The MDS (blister-pack) system is provided by Lloyds Chemists – a good service is reported. PRN medication is provided mainly in the form of analgesics. Records relating to this were not clear, signatures were not indentifiable. It was unclear exactly when the medication had been given and the dose given. There was not count of this or other medication and this is required. There were 4 requirements relating to these outcomes in the last report - Two have been satisfactorily addressed two have not and are repeated in this report. They are the outcome of the Occupational Therapy assessment carried out – this should be forwarded to CSCI when concluded and audit and improvement in medication recording. Church Lane, 88 DS0000030401.V322082.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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are listened to and adult protection procedures tested and satisfactory. Sense will inform CSCI of the outcomes of an investigation being completed. EVIDENCE: There is a complaints procedure in place which is available in the home and is satisfactory. Only one resident could practically use the complaints procedure and stated he understood its purpose and procedure. All residents have family visitors and contacts on a regular basis and this provides some opportunities for residents dissatisfaction to be identified. A complaint received by the Commission has beendealt with by the Sense organisation and a referral made by the home under Vulnerable Adults procedures had been determined and notified to CSCI. Another issue referred under the Vulnerable Adults procedures is presently being finalised. Sense staff have kept the Commission informed of progress in these matter by letter. Sense will notify the Commission when the remaining matter is completed. The homes procedures for referrals for adult protection have been tested and have proved satisfactory. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 20 Church Lane, 88 DS0000030401.V322082.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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Significant improvements to the environment have been made. Some further work is needed to complete a high standard environment, well adapted to meet the needs of this resident group. EVIDENCE: The home is in keeping with the local community and not distinguishable as a care home. It is a large, spacious detached house in its own grounds with a large secluded south-facing garden at the rear. The home has been adapted well to cater for the needs of up to 5 deaf/blind people. It is well presented, comfortable and homely. Furnishings are along Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 22 domestic lines and accommodation on the ground floor provides a large lounge area, separate large dining area and a spacious kitchen. There are the usual toilet and laundry facilities and a new office has been provided (relocated from the send floor) and central to the living areas on the ground floor. On the first floor there is a gym/activity room and also a quiet room with sensory equipment where residents can relax in a therapeutic environment. All bedrooms are for single use and all have good en-suite facilities. Bedrooms are generally well personalised although the room of a recently admitted resident was not and efforts should be made to provide photographs and personalisation to reflect the persons individuality and family identity and support. There have been significant improvements to the environment since the last report. Carpets have been replaced on the ground floor and the whole of the reception area and dining area fitted with new vinyl flooring. This makes a positive impact on the ground floor area. This work was needed and disruptive to residents, so they were all taken on holiday for a week to Centre Parks returning only in the week prior to the inspection. The office has been relocated from the second floor to the ground floor. It is fitted well and located at the centre of daily living. The requirements of the last report relating to the environment have all been addressed, including repair to the uneven surface at the front of the building. Three further requirements are made relating to the environment: The kitchen units require replacement with doors and drawers missing. The Manager says she has obtained the required 3 quotations for replacement kitchen and this will hopefully be replaced in the near future. The dishwasher has been out of use for 6 months and needs repair or replacement. There is one fridge freezer in the kitchen area. Only half is available to store frozen foods, this is inadequate when the weekly shopping is accommodated. Additional freezer facility is required. Furnishings, fittings and equipment in the home are of good standard and present a very good standard homely environment. Bedrooms are all well furnished, spacious and all have en-suite facilities. All have their own doorbells with flashing lights used if residents are in their bedrooms. All rooms in the home have symbols/markings for residents to easily identify their own and communal rooms throughout the building. The outcome of an OT assessment is awaited. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 23 Standards of hygiene throughout the home were high. To the rear of the building there is a large decked/patio area facing a large garden and give total privacy. The area is much used in the summer months by all residents. The building is secure. There are keypad locks on external doors (automatically disabled in the event of the fire alarm being activated). Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels have increased in line with the number of people in residence and is satisfactory. Training is readily available to staff although there are some gaps which will be addressed. EVIDENCE: Since the last inspection all vacant places in the home have been filled. There are now 5 residents. The current staffing level provides 385 staffing hours per week. There are three people on duty throughout the waking day. (four on Monday when one member of staff does weekly shopping at supermarket) sometimes there are 4 if resident activity requires it or the PDW is working in the home. The staffing reduces to 2 on Saturday a.m. and all day Sunday. The Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 25 justification for this is that some residents go out with relatives and the programme of activities scale down at weekends to allow a more relaxed pace for residents. The staffing levels appear adequate for the perceived dependency levels of the current resident group. Four requirements were made in relation to staffing at the last inspection. Three have been satisfactorily addressed: Vacant posts have been filled with staff transferred from another Sense home that closed recently. Staff training records have been updated. A training matrix has been compiled and copy given to CSCI. Unfortunately on this unannounced inspection the Manager and Deputy Manager were not on duty – they hold sole keys to staff record storage – so it was not possible to check staff records again on this inspection. This in unavoidable if the balance between availability and confidentiality are correctly applied. Staff records showed that statutory training was required for staff in relation to First Aid and Moving & Handling. This must be arranged. There are presently 50 of NVQ trained staff in the home as required. Additionally 4 staff are studying NVQ at this time. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 26 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): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of residents are promoted and protected. Some further statutory staff training is required. EVIDENCE: At the time of the last inspection an Acting Manager (former Deputy) had been appointed following the prevous Registered Manager leaving the home. Since that time another Acting Manager was appointed by the providers. Her application for approval as Registered Manager was approved by CSCI two weeks prior to this inspection. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 27 The new Registered Manager was not on duty it was therefore not possible to assess her management style and effectiveness in relation to the standards. Staff on duty comprised members of staff transferred from another Sense home and person who has worked at Church Lane for several years. All staff were very helpful in providing information and views to the inspector concerning the home and made a valuable contribution to the inspection process. They were open and co-operative and examples were seen of positive engagement with residents. Fire safety was reviewed. Weekly tests of the alarm system and tests of the emergency lighting system had been carried out and fire fighting equipment serviced earlier in the year. 3 monthly fire drills including evacuation had been carried out and residents involved in those drills. The fire risk assessment had been reviewed as required in the last report. The Manager confirmed following the inspection that all matters raised in the West Midland Fire Officers letter dated May 2005 had been completed as required in the last report. A subsequent letter from the Fire Officer dated August 2006 required that further emergency lighting should be provided and this had been done the week prior to this inspection. Also - work to automatically disable the keypad locks on all external doors in the event of fire had also been completed. Checks showed that COSHH items were appropriately stored in a locked cupboard in the kitchen area. Staff training is required in First Aid and Moving & Handling as identified earlier in this report. Regulation 26 reports have been received by CSCI from the providers on a regular basis. Regulation 37 notifications had been received by the home during the year as required. The outcomes of the complaint investigation by the Providers and also outcomes of the Vulnerable Adults procedures will be notified to the Commission as soon as those matters are resolved. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 X 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 2 12 2 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X X X X X X 2 X Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 29 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 3 4 5 Standard YA6 YA11 YA9 YA18 YA18 Regulation 15(1)(2) Requirement Timescale for action 28/02/07 31/12/06 31/12/06 31/01/07 28/02/07 6 7 YA22 YA20 8 9 10 YA24 YA24 YA24 Care plans must be updated and reviewed. Previous timescale not met. 12(1) The needs of new residents must be reviewed, documented and updated to avoid skill loss 13(4) Risk assessments must be reviewed on a regular basis. Previous timescale not met 12(1)(a) Further review dietetic/nutritional needs of residents identified. 14(2)13(5) CSCI must be informed of the outcome of the OT assessment and action taken by the Manager. Two previous requirements not met. 22(3) Sense to notify CSCI of outcome of complaint and Vulnerable Adults referral. 13(2) Clearer recording of PRN medication and count of medication is required. Previous timescale not met. 16(2)(g) Dishwasher should be repaired or replaced. 23(2) (c ) Repair/replacement of kitchen units are required. 16(2)(g) Additional freezer space for food is required DS0000030401.V322082.R01.S.doc 28/02/07 31/01/07 31/01/07 28/02/07 28/02/07 Church Lane, 88 Version 5.2 Page 30 11 YA35 18(1)(c ) Staff training in First Aid & Moving & Handling is required. 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA24 YA25 YA11 Good Practice Recommendations It is recommended that draught proofing is fitted to the kitchen external door. Personalisation is required in bedroom identified Consider ways of extending residents involvement in domestic activities to increase social skills. Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Church Lane, 88 DS0000030401.V322082.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!