Inspection on 12/02/08 for 98 Beeches Road - Lyndel Homes

This inspection was carried out on 12th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

98 Beeches Road - Lyndel Homes 21/09/06

98 Beeches Road - Lyndel Homes 09/01/06

98 Beeches Road - Lyndel Homes 26/07/05

98 Beeches Road - Lyndel Homes 07/02/05

98 Beeches Road - Lyndel Homes 31/08/04

98 Beeches Road - Lyndel Homes 18/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 98 Beeches Road - Lyndel Homes 98 Beeches Road West Bromwich West Midlands B70 6HJ Lead Inspector Ms Linda Elsaleh Key Unannounced Inspection 12 & 14th February 2008 09:30 th 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 98 Beeches Road - Lyndel Homes Address 98 Beeches Road West Bromwich West Midlands B70 6HJ 0121 580 0759 0121 515 2544 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) Mrs Delores Matadeen Mrs Delores Matadeen Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two service users identified in the variation application dated 30 September 2005 may be accommodated at the home in the category MD(E). This will remain until such time that the identified service users placements are terminated at which time the category will revert to 9 service users in the category MD only. 21st September 2006 Date of last inspection Brief Description of the Service: 98 Beeches Road is a residential home providing 24-hour care and support for 9 people experiencing mental ill health. The property is an extended 3 storey, mid-terrace. This edwardian building forms part of the Lyndel Care Homes Company. It is situated in a residential area close to West Bromwich town centre and has good transport networks. On the ground floor there is one double bedroom, lounge, kitchen, shower room including a toilet and wash hand basin, two additional toilets, and a tworoomed conservatory used as a dining and recreation area. Access from the conservatory leads to a paved courtyard. On the first floor there are four single bedrooms, one bathroom with bath, toilet, wash hand basin and a small office. Finally, on the second floor are three single bedrooms, one shower room with toilet and wash hand basin. The home should be contacted directly for up to date information about the fees for this service. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This unannounced inspection was carried out on 12th & 14th February 2008. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults (18-65) and report on its progress since the commission’s last visit. Our findings are based on the information we have received about the service, examination of relevant records and documents kept at the home, discussions with the acting manager, staff, people who use the service and a tour of the premises. The service continues to be managed by the acting manager and the registered person regularly visits the home and provides ‘on call’ support. An application to register the acting manager has not yet been submitted to the commission. What the service does well: What has improved since the last inspection? The acting manager has completed the National Vocational Qualification Level 4 and is due to commence the Registered Manager’s Award (RMA). Staff who are responsible for looking after medication have completed a course on the safe handling and administration of medication. The re-decoration of bedrooms and some communal areas has been scheduled to take placed in the near future. The service has revised its arrangements for people who wish to smoke to comply with the new legislation. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is adequate. Information provided to prospective service users should be up to date to enable them to make an informed choice about where to live. Prospective service users should be involved in the service’s process for assessing how it will meet their needs and aspirations. Opportunities are provided for prospective service users to visit and “test drive” the home. The service should provide each service user with an individual contract that specifies the agreed conditions of residency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A revised of the homes Statement of Purpose and Service User Guide was on display in the home at our last visit. However, during this visit the Statement of Purpose and Service User Guide provided was dated March 2004. Four of the people who use the service told us they received information about the home before they moved. They did not comment on the information provided to them. Two files were examined in detail. One file belonged to the 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 9 most recent person who had come to live at the home. There were no details of the information the service had provided him with. The service is advised to develop a system to ensure all information provided to prospective service users/people who use the service is the most up to date. The acting manager told us the service has revised its referral process to ensure care management assessments for prospective service users are obtained from the relevant agencies. Copies of these were seen on the two files we examined. The service also carries out its own assessment to identify how it will meet the individual’s needs. The file of the most recently admitted person shows the assessment carried out by the service was incomplete. Three of the twelve assessment areas had been completed. The document was not signed or dated. A member of staff told us the original assessment information was being transferred to the computer and amended, where applicable, to bring the information up to date. The acting manager was informed of the need to clearly identify this information as a “re-assessment of needs” or “review”. The amendments should be dated and include the name and designation of the person who carried out the re-assessment/review. There is little evidence to show the most recent person to live at the home was involved in discussions about his care needs or of a planned introduction to the home. However, he did tell us he remembered visiting the home before he moved in. Another service user told us he visited the home and stayed overnight prior to moving in. An up to date copy of the contract/statement of terms & conditions between the home and the people who use the service were not available in the files were examined. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 11 6, 7, 8, 9 & 10 Quality in this outcome area is adequate. Service users should be more involved in planning for their care and how their changing needs and personal goals will be met. The service should demonstrate through its recording how it supports service users to make their own decisions and, if applicable, how decisions are made on their behalf. Service users should be provided with more opportunities to meet to discuss the day-to-day running of the home. They would benefit from a more planned approach to key worker sessions and the key worker could provide support to enable them to express their views more confidently. The service has a process for carrying out individual risk assessments, but care needs to be taken to ensure these are completed for all areas where concerns are raised about the safety of individuals and others. Service users know how information about them is kept. However, the service should review its current administrative arrangements to ensure their privacy and right to confidentiality is fully respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We discussed the service provided by the home with people who use the service. They told us they were generally satisfied with the support they receive and are looking forward to having their bedrooms re-decorated. The files examined contained care plans, risk assessments and supplementary information about the needs of people who use the service. Care plans are in the process of being entered onto the computer. The content and quality of the information in the paper and computer formats vary. The format for care plans on the computer includes a section for recording the views of the individual. This section has not been completed. One person’s plan states he attends art classes and has a part-time job. Daily records are kept by staff and used by the key worker to produce a monthly report on the individual’s progress. The reports for this person show “no 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 12 change” to his routines or care. However, we were told it has been 12 months since he last attended art classes or his job. A review of his care was held in April 2007 and was attended by members of his family and representative from the funding authority. The minutes of the meeting do not include details of discussions about his art classes or part-time job. The second person’s file we looked also shows a review of his care plan has not been held during the last six months. We discussed with the person in charge the need to monitor recordings made by staff to ensure accurate information is available for reviewing care plans. Care plans should be reviewed and updated, where applicable, at least once every six months. Staff told us there was concern for the safety of one person when he leaves the home alone. They said strategies for managing this were discussed with his consultant. There was no reference to the discussions and a risk assessment for this was not available in his file. Staff said the concern for his safety had reduced. The individual told us he had settled at the home and was satisfied with the support he was receiving. The monthly reports produced by key workers do not include the views and wishes of the individual. People who use the service told us they are consulted about meals. The minutes of four group meetings were available for the period between September 2006 and February 2008. Items for discussion included requests for more planned outings and staff asking for support from the group to help keep the home clean and tidy. Staff raised the issue of personal hygiene and medication with the group. This was discussed with the acting manager, who agreed it would be more appropriate for the key worker/s to discuss such issues in private with the individual/s concerned. This would ensure they are treated with dignity and their right to privacy respected. Risk assessments are carried out by the service. The majority of which have been reviewed in recent months. However, staff informed us one person is known to smoke cigarettes in his bedroom. They stated this was in breach of the home’s rules and to ensure his safety and the safety of others they needed to be vigilant. A risk assessment was not available on the individual’s file. The files examined did not include information about how individuals are supported to take risks as part of an independent lifestyle. People who use the service spend most of their time, when at home, in communal areas such as the front lounge. There are lockable facilities for storing people’s records. The computer used by staff, previously kept in this room, has been moved to the small office upstairs. There continues to be times when staff make and receive telephone calls in this room. This needs to 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 13 be closely monitored to ensure the rights of people who use the service to confidentiality and privacy are maintained. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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): 11, 12, 13, 14, 15, 16 &17 Quality in this outcome area is adequate. Service users should be provided with more opportunities to maintain and develop individual living and social skills and participate in a range of activities. The service continues to support service users to maintain positive relationships with family and friends. Staff respects the right of service users to follow their own daily routines. Service users are offered meals that meet their dietary needs and personal preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 15 Staff addresses people who use the service by the name they prefer to be known by. This is recorded in their file on the basic information form. We were informed by staff the people who use the service show little interest in attending day centres, college or local facilities. One resident has a National Vocational Qualification Level 2 certificate in Food Preparation and Cooking. This was achieved several years ago and no evidence was available to show staff encourage and support him to use these skills. Some staff said that an increase in staffing levels would enable them to provide encouragement and more support to individual’s to maintain/develop their independent living and social skills. Staff reported the progress that has been made by one person. He is now travelling independently and contacts staff when he has reached his destination and tells them when to expect him back. There is no record of this on his file. Care plans make reference to people’s individual interests and daily pastimes, such as going to the local shop, watching television or spending time relaxing in their bedrooms listening to music. Daily records seen for two people who use the service does not include reference to any support provided by staff or participation in activities during the last four weeks. A copy of the home’s activity programme, dated 2006, is displayed on the notice board. With the exception of the minutes for one group meeting no other records were provided of discussions held about activities or holidays. Staff told us group outings have not taken place during the winter months because of lack of interest and transport not being available. People who we spoke said they are able to choose how they spend their time, but “would like to be told what activities are available and would like to go out a little more often as a group”. This is in contrast from the previous inspection when people who use the service and staff spoke positively about participating in new activities. People who use the service told us they continue to receive support from staff, where applicable, to maintain positive relationships with family and friends. Details are available on the individual’s file and records are kept of contact made and visits/meetings that have taken place. One person recently went shopping of new clothes with a relative. Individuals have unrestricted access to all communal areas in the home. However, for health and safety reasons people using the kitchen to make drinks or wash up are supervised by staff. A number of people who use the service chose to smoke. The room at the rear of the conservatory has been re-designated a “smoke free zone” to comply with legislation. The service has provided a sheltered area at the rear of the premises for use by people who wish to smoke. People who use the service told us they understood the reasons for this change. A revised smoking policy has yet to be produced to reflect this change. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 16 Individual dietary needs and preferences are catered for. The service monitors nutritional needs and dietary intake. People who use the service told us they are consulted about their meals on a daily basis and are pleased with the quality of the food prepared by staff. The menu for the day is displayed on the notice board in the dining room. The mid-day meal was a quiet affair with little conversation or interaction. Staff did not dine with the residents, but took it in turns to eat their meal later. The home was advised at the last inspection to review this arrangement in an effort to create a more social atmosphere for people who use the service. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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 & 20 Quality in this outcome area is good. Service users receive support with their personal care in the way they prefer. Arrangements are made to ensure their physical and emotional needs are met. Suitable systems are in place for the management of medication. However, to ensure the well-being of service users is fully protected arrangements should be agreed for the management of medication on their behalf when they are away from the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some people who use the service require varying levels of support with personal care. The support required ranges from prompts to maintain good personal hygiene routines to assisting others with dressing and bathing. Staff described the levels of support needed by individuals. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 18 Records show regular arrangements are made for people who use the service to receive general and specialist healthcare checks. A member of staff accompanies those who need support to attend appointments. Information about medical conditions affecting individuals is available on their files. Advice is sought by the service from relevant health care professionals and, where necessary, meetings are arranged to discuss any concerns. An up to date list of prescribed medication is kept on the files of people who use the service. The service manages their medication on their behalf. The prescribing GP or consultant carries out regular reviews of the individual’s medication. A risk assessment provides information about the effects of drinking alcohol whilst on medication. Guidance for staff has not been provided to staff in identifying possible changes in the mental health needs of individuals. A copy of the service’s procedures for the safe handling and administration of medication is displayed on the notice board in the office on the first floor. A copy is kept in the medication folder with a list of staff authorised to administer medication. A sample of their signatures and initials are kept for identification purposes. The current medication administration record sheets are also kept in this folder. Examination of staff training records show staff with responsibility for managing medication have completed a course in the safe handling and administration of medication. Medication is kept in a locked facility. However, consideration is recommended in finding a more suitable location. Staff were observed administering medication in accordance with the service’s procedures. The key worker for one person explained the reasons why his medication was managed on his behalf by the service. However, suitable arrangements have not been identified for managing his medication when he is away from the home. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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 & 23 Quality in this outcome area is good. There is a system in place for service users and/or their representative to express their views or raise any concerns they may have. The service has suitable procedures and systems in place to protect service users from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is displayed on the notice board. Information provided by the service states no complaints had been received during the last twelve months. No complaints have been reported to the commission. Adult protection procedures are displayed on the notice board in the first floor office and the service has a copy of the local authority’s Safeguarding Vulnerable Adult Procedures. Arrangements are made for staff to attend adult protection training. Information provided by the service states no protection issues have been raised by or with them over the last twelve months. No concerns have been raised with the commission. The service has satisfactory systems in place for managing the personal allowance of people who use the service. The arrangements are included in 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 20 the individual’s care plan. Records are kept of all transactions made by the service on their behalf. One person was identified as being fully independent in managing his own finances. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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 & 30 Quality in this outcome area is adequate. The proposed plans for the re-decoration and refurbishment of the premises will provide service users with a more homely and comfortable environment in which to live. Appropriate hygiene standards are maintained in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises identified there were areas in need of re-decoration and some items of furniture replaced. The acting manager told us the re-decorate and refurbishment all bedrooms and some communal rooms had been planned. However, a programme for this work was not made available. We were also informed of plans to refurbishment of the kitchen and new units had been ordered. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 22 Work has been carried out to make good the damage to some bedroom walls and ceilings ready for decorating. Our discussion with one person who uses the service about the proposed decoration told us he liked the colour of his bedroom and did not want it changed. The acting manager re-assured him he could chose the same colours and a fresh coat of paint would freshen up his bedroom. The need to re-cover or replace the armchair in the bedroom on the second floor was identified at the previous inspection. No action has been taken and we were informed this would be addressed as part of the refurbishment programme for this room. There is no evidence that other people who use the service have been consulted about these plans. The small office on the first floor is mainly used for storing files. Staff have begun to some time in the office updating the records held on the computer. The room has no natural light or ventilation. This needs to be included in the service’s plans for improving facilities within the home. A supply of dry foodstuffs and frozen food is kept in the cellar. We were informed flooding had occurred and the investigation commissioned by the home could not identify the cause. As a precautionary measure a pump has been fitted to remove water should this happen again and the storage height for items has been raised. There have been no further problems. The home has a paved patio area at the rear of the premises. There are garden chairs and plants pots providing a pleasant area for people to sit in during fine weather. Two people told us they look after the plants. Cleaning materials are stored in the laundry area and this room is kept locked when not in use by staff. Protective clothing, such as disposable gloves and aprons, are provided for staff use when carrying out domestic duties or personal care. People who use the service should be encouraged and supported to carry out some laundry tasks, according to their ability, as part of developing their independent living skills. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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, 33, 34, 34, 35 & 36 Quality in this outcome area is good. A team of qualified staff team are employed to care for service users. However, regular supervision sessions and programmes for their personal development would improve the support provided to them in carrying out their duties. The service has reviewed its recruitment policy and procedure to ensure people who use the service continue to be fully protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no changes in the staff team. A review of the home’s recruitment policy and procedures was carried out in December 2007. There are no outstanding recruitment issues. The rotas show a minimum of two staff on duty during the morning and four staff are usually rota-ed for duty between 12:30 and 17:00. We were informed staffing levels are increased at other times of the day, when required, 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 24 to provide support to people attending appointments or for them to participate in activities. Over the last four weeks the rotas indicate no additional support has been required. However, 50 of staff that responded to our survey said additional staff would enable key workers to spend more time with the people who use the service on an individual basis. Information provided by the service shows all staff hold the National Vocational Qualification (NVQ) in Health & Social Care Level 2 or above. We looked at the files kept of three staff. A copy of the Level 3 certificate was available on a senior member of staff’s file and a copy of the Level 4 certificate was available on the acting manager’s file. The acting manager told us she is due to commence the Registered Manager’s Award (RMA) in the near future. Certificates for the Safe Handling and Administration of Medication Level 2, dated 2007, were available and we were told four more staff (including waking night staff) had also attended this training. Attendance certificates for working with people with dementia, dated September 2007, were seen on two files. One member of staff told us they had recently attended an introduction seminar to the Mental Capacity Act. There was no planned programme identifying how the training needs of the service will be met over the next 12 months. However, we were informed arrangements had been made for training in health & safety, basic first aid, basic food hygiene and adult protection to take place over the next 12 weeks. The minutes of four staff meetings were available for the last 12 months. The content of these meetings was discussed with the acting manager. She said she is reviewing the frequency of these meetings and agreed a more planned approach should be taken to ensure the needs of the people who use the service are discussed. A programme for staff to receive planned supervision was not available. The acting manager told us she receives supervision from the registered person. Our survey asked staff to indicate how often their manager meets with them to provide support and discuss their performance - 40 said they meet regularly, 20 often and 40 sometimes. The records examined show in 2007 a total of 6 supervision sessions were held with three staff - 3 sessions with one member of staff, two with another and one with the acting manager. The records for these meetings included individual performance, future targets and training and development needs. All staff should receive a minimum of six supervision sessions per a year, an annual appraisal and an individual training and development programme such be produced. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate. Service users would benefit from a better understanding of the roles of the person managing the day-to-day running of the home and the registered person. For service users to be confident their views underpin all self-monitoring, review and develop of the service a comprehensive quality assurance system should be implemented and the future plans for the service made available to them. The service has procedures to promote and protect the health, safety and welfare of service users. However, systems to ensure these procedures are implemented should be improved to ensure the safety and best interests of service users are more fully protected. This judgement has been made using available evidence including a visit to this service. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 26 EVIDENCE: The registered manager for the service is the responsible individual. At our last visit she informed us she had delegated responsibility for the day-to-day running of the home to the acting manager. The registered person told us she was providing support to the acting manager to build up her confidence. She has since completed NVQ Level 4 and will be commencing the Registered Manager’s Award (RMA) in the near future. The rotas show the acting manager has full responsible for the day-to-day management of the home and the registered person provides ‘on call’ support. The acting manager told us the registered person visits the home and is easily accessible by telephone. As reported in the previous section of this report the acting manager is not receiving regular supervision and does not have a planned programme for her personal development. An application has not yet been submitted to the commission for her to become the registered manager for this service. There is no system in place for the service to monitoring of its own performance against its stated aims and objectives. However, it has sought the views of relatives and other stakeholders. A comment that the “staff are wonderful” reflects the overall satisfaction they expressed about the service. An annual development plan should be produced based on a comprehensive review of the service’s own performance and made available to the people who use the service and relevant stakeholders. Details of who to contact in the event of an emergency are kept in the front of the folders containing information about the premises, equipment and appliances. In general, the records of safety checks carried out by the service are good. However, the folders are disorganised and show the annual reviews for fire risk assessments and the testing of portable electrical appliances are overdue. To reduce the risk of such oversights a system should be introduced for monitoring safety record checks. The staff team are aware of the need to follow safe working practices. They commented positively about the health & safety training they had received. However, the records do include all the training identified by them. Their individual training records should be kept up to date and annual training programmes should be produced that includes staff attendance on refresher courses are required. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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 1 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 2 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 3 X 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA42 Regulation Requirement Timescale for action 02/06/08 2. YA42 23(4)(c)(v) The registered person must make arrangements for fire risk assessments to be reviewed to ensure service users are kept safe. 23(2)(c) The registered person must 02/06/08 make arrangements for electrical equipment in the home to be tested to ensure service users are kept safe. 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 An up to date copy of the Statement of Purpose and Service User Guide should be available in the home and provided to prospective service users to enable them to make an informed choice about where to live. Prospective service users should be fully involved in the assessment of their needs and how these will be met. These, and subsequent assessments and reviews, should be signed and dated. Each service user should be provided with a contract that DS0000004850.V351018.R01.S.doc Version 5.2 Page 29 2. YA3 3. YA5 98 Beeches Road - Lyndel Homes 4. YA6 specifies their agreed conditions of residency with the service. Care plans should be reviewed at least once every six months with the service user, his relatives/representatives (where appropriate) and relevant agencies. Changes in care needs should be recorded in the service user’s care plan. Written records should be kept of all consultations held with the service users such as how their needs are to be met and the day-to-day running of the home. Risk assessments should be carried and details of action to be taken where concerns are raised about a service user’s safety when away from the home. Risk assessments should be carried and details of action to be taken where concerns about fire safety are raised about smoking in prohibited areas in the home, such as the bedroom. Staff should respect service users right to privacy by discussing issues of a personal nature in private. Administrative tasks carried out in the lounge should be closely monitored to ensure service users’ right to confidentiality is observed at all times. Suitable arrangements should be made to support service users to maintain and develop social living skills. Service users should be provided with opportunities to participate in a varied programme of activities. The smoking policy should be revised to reflect the home’s changes in its arrangements for service users who wish to smoke. Staff should be provided with guidance for identifying possible changes in the mental health needs of individuals. Suitable arrangements should be made for managing medication on behalf of service users when they are away from the home. A programme of re-decoration and refurbishment should be produced for the planned up keep of the home. The armchair in the bedroom on the second floor should be re-covered or replaced to protect against the possible spread of infection. Staff should be provided with regular opportunities to meet as a group to discuss the service users progress and raise any areas of concern. Training records for staff should be kept up to date to and plans produced to meet individual training needs to ensure the needs of service users continue to be met by a suitably DS0000004850.V351018.R01.S.doc Version 5.2 Page 30 5. 6. YA8 YA9 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. YA10 YA10 YA11 YA14 YA16 YA19 YA20 YA24 YA24 YA33 YA35 98 Beeches Road - Lyndel Homes 18. 19. 20. YA36 YA37 YA39 trained staff team. Each member of staff should receive a minimum of six planned supervision sessions each year and an annual appraisal of their performance. An application should be made to the commission for the registration of the person who is in full-time day-to-day charge of the home. A comprehensive quality assurance system should be introduced to monitor the service’s performance against its stated aims and objectives. The service should produce a development plan for the home based on its annual review of the service. 98 Beeches Road - Lyndel Homes DS0000004850.V351018.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 98 Beeches Road - Lyndel Homes DS0000004850.V351018.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. 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