Inspection on 27/11/06 for Albert Road (8b) (Hightrees)

This inspection was carried out on 27th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albert Road (8b) (Hightrees) 22/02/08

Albert Road (8b) (Hightrees) 02/02/06

Albert Road (8b) (Hightrees) 05/07/05

Albert Road (8b) (Hightrees) 22/02/05

Albert Road (8b) (Hightrees) 18/05/04

Albert Road (8b) (Hightrees) 24/06/03

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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 Albert Road (8b) (Hightrees) Harborne Birmingham West Midlands B17 0AN Lead Inspector Peter Dawson Key Unannounced Inspection 27th November 2006 09:30 Albert Road (8b) (Hightrees) DS0000016966.V321557.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 Albert Road (8b) (Hightrees) DS0000016966.V321557.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. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albert Road (8b) (Hightrees) Address Harborne Birmingham West Midlands B17 0AN 0121 428 3423 F/P 0121 428 3423 ruth.gavin@sbpct.nhs.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Accord Housing Association Limited Ms Ruth Gavin Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 2nd February 2006 Brief Description of the Service: 8B Albert Road, Hightrees, is a purpose built care home, which accommodates five men, who require care and support as they have a learning disability and some behaviour that challenge the service. The home is situated within a residential area of Harborne, and is close to local amenities, and transport links. The home has three ground floor bedrooms, a communal lounge, dining room, kitchen, and shower room. On the first floor are a further two bedrooms, a staff sleep in room/office, and a bathroom. The home offers off road parking for approximately four cars. The first impression of the home is very positive. Accommodation is spacious, bright and homely. Some replacement of furnishings are required but accommodation is basically good. The home has a stable staff team who understand and can meet the needs of the men accommodated and provide individualised plans of activity to positively engage residents inside and outside the home. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by one inspector from 10 am – 5.30pm. A pre-inspection questionnaire had been completed by the service prior to the inspection and provides a basis for some information contained in this report. One written feedback form received from a relative. There was an inspection of all the communal areas of the home and several bedrooms were seen by invitation of the residents. Documents inspected included care planning and personal care information, medication records, staff rotas, fire records and other documents relating to the inspection process. All five residents were seen at various times throughout the day of the inspection, both together and separately. All five members of staff on duty were seen, spoken to and assisted positively with the inspection. There was an open discussion between manager, staff residents and inspector. The impression gained was of a good standard environment (some replacements needed) and a high standard of care provided to this group of five men, allowing them opportunities for personal development in all areas of their lives and supported by a well trained and professional staff group. A written feedback from a relative expressed satisfaction with all aspects of care. The weekly fees at Hightrees are not known and a requirement made in relation to this. What the service does well: A small group of 5 men live together in a pleasant, homely supportive environment. Staff are well trained and have the skills and experience to provide a service to people with complex needs. Several residents exhibit challenging behaviours but these are well managed in a professional way to minimise the risks to other residents and staff. There was evidence of chosen lifestyles. Residents were seen making choices about their daily lives, their views sought by staff who listened and responded positively to them. Care planning information and risk assessments are to a good standard and reviewed on a very regular basis with residents. Residents do not attend day service centres. All activities are provided by the home with an accent upon community involvement and social inclusion. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 6 All residents have annual individual holidays, supported by staff. Cruises and holidays to Tenerife have been chosen and enjoyed by residents. The environment is homely and comfortable. The atmosphere relaxed and residents encouraged to take part in a normal family lifestyle, simultaneously improving their social skills. Residents were seen accessing their bedrooms and all areas of the home throughout the day as they wished. What has improved since the last inspection? What they could do better: Nine requirements are made in this report. Five relate to improvements required to the environment. The hallway carpet should be replaced, together with the carpet in the lounge area and also the furniture in that area. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 7 Lino in a bedroom should be replaced with carpet and some bedroom furniture replaced. Weekly fees must be clarified and information available to residents and relatives. This information must be in the Statement of Purpose and in contracts. Greater clarity of medication records relating to PRN medication are needed. Staff recruitment procedures must be improved to ensure all required checks are carried out to ensure the protection of residents. 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. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Minor updating of statement of purpose/service users guide needed. Weekly charges are not known and work required to obtain and make the information available. Admissions procedures are good. EVIDENCE: This is a small home with 5 people. Four have been resident since it opened in 2001 and one person admitted in 2005. The circumstances surrounding that admission were inspected previously. All required pre-admission assessments and appropriate introductions had taken place and met required standards. Contracts are in place with Accord Housing Association but apparently not with Social Care & Health. The weekly fees for care provided at Hightrees are therefore not known to residents. The statement of purpose and service users guide were inspected and provided necessary information. Some minor updates were needed e.g. change of staff. There was not a current copy of the documents in the reception area but these will be put in place. The weekly charges are not in the Statement of Purpose and this is required. The charges were not known to staff and should be available from Care Management personnel. Albert Road (8b) (Hightrees) DS0000016966.V321557.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans detail the needs of residents and how they are to be met. Residents are involved in daily decisions about their lives and consulted about their wishes in individual monthly meetings. Confidential records are secure. EVIDENCE: Care plans were seen relating to 2 residents. They contained all required information to meet needs. Plans seen contained information relating to: daily routines, strategy regarding behaviours including known trigger factors, medication list with side effects and protocols for administering PRN medication, family contacts, healthcare, healthy eating, dietetic advice. Risk assessments were in place and seen relating to: use of kitchen, road safety and going unescorted into the community. Risk assessments are reviewed on a monthly basis as part of care planning information. Plans were person centred. There is a monthly review of care plans. Residents meet on a monthly basis with key workers to discuss the persons wishes and plans. Arising from this are positive outcomes. It was Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 11 recommended in the last report that previous goals are discussed at subsequent meetings to assess whether they have been met. The Manager wishes to further pursue this, seeing it as a positive way of measuring progress and satisfaction for the person. Staff individually sign care plans to indicate they have read and understand the actions required of them. The monthly review has specific subject headings to ensure detailed review of all aspects of care, these include family contact for the month, daily routines, activities, challenging behaviours etc. All reviewed and reported upon separately. Residents meeting are not held formally. The 1:1 monthly meetings with residents are seen as a more positive individual option. Risk taking was discussed and the Manager will review the continued use of the keypad on the main entrance door as a means of re-assessing the risks involved which currently restrict residents access from the building. – Residents have to be “let out” by a staff member which is not conducive with the independence that the home promotes in other areas of daily living. Confidential records are stored securely. There was a breach of this found on the last inspection when information was found on the notice board. This was removed immediately and was due to staff error. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Opportunities for personal development and choice of lifestyle are offered to all residents. The majority of activities are accessed in the community with support from staff. There has been a significant improvement in moves towards more healthy eating for all residents. EVIDENCE: The lifestyles of residents were observed in the home from breakfast to teatime. Flexible rising and breakfast time is evident. One person rising 10.30 a.m. preparing his own breakfast of cereal, toast and tea. He was given a choice of activity and chose to visit the town with a staff member as his gardening project for the day had been cancelled. Day service facilities are, refreshingly, not used by this service. All residents have individual activities arranged in discussions with them “on the day”. A support worker has specific responsibility for arranging activities on a daily basis, some are planned days ahead but always in discussion/agreement with Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 13 the resident. Choices were seen to be made during the inspection. Four of the five male residents chose to go out to local venues two went together with staff the others separately with staff (residents do not go out unescorted). Staff are allocated accordingly when daily choices are made. One chose to stay at home although he usually attends a local activity group which he enjoys but for the first time refused to go. He was given options but chose to stay at home. Staff felt it was not appropriate to further persuade him and he was simply given time out to relax and watch TV etc. He did this during the morning. He said he likes to go swimming and to the gym which staff support him in, He later went swimming in the afternoon with a member of staff. To further encourage him 2 pieces of gym equipment are provided in the lounge area which he does use. As part of his healthy eating plan following dietetic advice he walks daily to the local shop to buy fruit. The above are examples of individual choices seen to be made. The range of activity include: art classes, college work, games, keep fit class, swimming, music/videos, cooking, gardening, bowling, cinema, pubs and restaurants. Most accessed outside the home some internally. All residents are offered an annual holiday with an allocation of £400 – the resident provides any additional cost. There have been holidays in Spain, Tenerife, cruises and this year to Skegness and Jersey by request. On display photographs capture the moment and enjoyment for future proof, discussion and pleasure. All holidays are individual experiences rather than group holidays. Transport is readily available. The home have a 7 seat person carrier. Additionally public transport is readily available and used. The town centre is within a short walking distance and accessed daily. There is a daily jobs rota to include domestic tasks specifically to promote skills and independence. These are tuned to individual skill levels. One person enjoys domestic routines, was seen happily washing dishes after the evening meal. He said he had made a Christmas cake he was particularly proud of. Another resident makes drinks throughout the day - each time asking first if he can do so. He is told each time that he does not have to ask, but it is difficult to combat past institutionally acquired behaviour. All residents have access to the kitchen area with various risk assessments having been carried out and documented. Family contacts are encouraged and promoted. All residents have visitors, some regularly some less regularly. One person with no previous family contact has recently renewed contact with his mother and is taken to North Wales regularly to see her. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 14 At the time of the last inspection requirements were made following concerns about unbalanced diets, weight gain and non-healthy eating. A lot of work has been done in this area. The dietician has been involved in assessing special dietary requirements and approved new menus created in the home with resident input. There has been considerable improvement and a move towards more healthy eating. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 15 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 adequate This judgement has been made using available evidence including a visit to this service. Residents have complex needs which are supported in a positive and professional way to meet their needs. Physical, emotional and psychological needs are evidenced being met. Some areas of medication administration must be strengthened. EVIDENCE: The inspector was pleased to meet all five of the residents. All men were seen to be supported to undertake personal care in the way and at the time they preferred. Care plans seen recorded the actions required to by staff to meet personal care needs. Health care records seen showed a chronological record of interventions by health care professionals from dental appointments to Consultant Psychiatrist appointments. There were recorded interventions by the psychological services. Residents had access the usual well-man clinic services provided by the GP practice. Care plans required in previous reports to underpin low fit diet and healthy eating have been provided. Dietetic advice has been sought and actioned. A resident on specific diet has lost 1 stone in weight as a result. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 16 The home specifically provides a service for people with challenging behaviours. Records showed that 14 such incidents had been recorded since the last inspection. These were discussed in detail with the Manager and records seen to support the incident actions taken. There had been some minor injuries to residents and staff arising from these incidents and referrals made even to police and vulnerable adults personnel. Further action had not been taken by those agencies but the inspector was satisfied that all the necessary steps had been taken to assess risks, record potential triggers for such behaviour, some with assistance from Psychological Services and had handled difficult situations appropriately and professionally. Staff have considerable experience in this area. All have received training in the management of aggressive behaviours, minimising confrontation and diversionary tactics – all used appropriately to diffuse difficult situations. Restraint is not used in the home and the training and experience of staff avoids such potential situations. Some residents have diagnoses of autism and all staff have undergone specific training relating to aspects of autism. Medication records were inspected. MDS (blister packs) are provided by Boots Chemists a good service is reported. All 10 staff administering medication have received certificated training. All medication when administered is signed by 2 staff for additional accuracy/security. Some areas of medication administration need to be strengthened. There was a recent minor misunderstanding about medication relating to a lack of knowledge of the system and which did not have any consequences. On inspecting the system PRN medication had been administered on 2 days which were not clearly recorded with time and clarity of signatures. Records did not readily indicate the reasons for the medication given. There must be clear and accurate recording of PRN medication. There had been a recent shortfall in the number of Olanzapine tablets at the end of the monthly period (not in blister packs) the reasons for the shortfall were not identifiable. A system has been introduced to avoid this in future with a count and separate recording of the medication in question. All medication returned to the pharmacy is recorded, signed by staff but not countersigned by the pharmacy. This should be done to complete the medication audit trail. The needs of residents in relation to ageing, illness and death have been ascertained and recorded. This applies to all except one resident who has been recently re-introduced to this family. The Manager intends to pursue the matter as soon as the opportunity to do so is presented. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. There is an open culture at Hightrees with opportunities for residents and staff to raise ideas and concerns. Training in adult protection has been provided for all staff. EVIDENCE: There are opportunities for residents to express their views in the daily situation and in the regular monthly 1:1 discussions with key workers which are documented. There is a complaints procedure in place which is also pictorial and available in all bedrooms and the reception area for residents and visitors. The procedure meets the requirements of Regulation 22. There have been no complaints to the home or to the Commission since the last inspection. Staff have received training in Adult Protection and there has been further training for new staff since the last inspection. All staff are aware of the procedures for reporting suspected or actual abuse and have knowledge of the various forms of abuse. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. The service presents a homely, comfortable and safe environment. The refurnishing and re-carpeting of some areas is needed and well documented. Bedrooms are well personalised and used as extensively as residents require. EVIDENCE: There are reported improvements to the environment. There has been a new kitchen fitted recently. The home presents a homely domestic environment. It is spacious, bright, well decorated and generally well maintained. The weak area is in the furnishings/carpets that required replacement. Several requirements have been made in previous reports and some repeated in this report, for replacement furniture and carpets. The carpet in the lounge area requires replacement due to spillages over time and presents some odours. The furniture in this area is “tired” and also needs replacing, although the Manager reports that choices have been made and the Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 19 replacements hopefully imminent. The carpet in the hallway is badly stained and cleaned weekly to sustain minimum appearance. This requires replacement. The hard-floor vinyl flooring in one bedroom on the ground floor should be replaced in the interests of comfort and homeliness. New furniture is required in the same ground floor bedroom to provide adequate drawers/storage space for clothing and personal items. The wardrobes are poorly constructed and doors do not close. It is clear from the reports provided by Accord Housing Association to the Commission that some replacements are in process or planned. These outstanding issues are needed to complete the overall presentation of the home. Three previous requirements have been resolved: Work on the heating system in the home has now provided a sustainable and reliable heating system throughout the home. The problem of adequate drainage in the ground floor walk-in shower area has been resolved. Odour control in the ground floor toilet area has been reduced/eliminated with further work. The issue of stark appearance of the bathroom areas have been improved with decoration by staff/residents. All bedrooms are for single use and some seen with consent from residents. They were well personalised, bright and adequately decorated. Some refurbishing is needed but all had adequate space and TV/DVD/Video/music facilities provided by residents to suit their needs. Personal effects were mainly prolific with posters/photographs on walls. One resident rejects basic personalisation and changes to his room this is respected although he is encouraged to gradually extend this. There is a pleasant and private garden area used considerably in the summer months which is a safe area for residents. The building is well maintained and presents well in the community. It is not identifiable as a home. All areas of the home were clean and hygienic. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 20 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 adequate This judgement has been made using available evidence including a visit to this service. There is a committed, competent and well trained staff team. Staff records indicate a shortfall in the protection of residents. EVIDENCE: Virtually all staff work full-time in the home. Some have been employed since the home opened 5 years ago. There is certainly some continuity although there have been recent staff changes. Many staff have worked together for a long period. The atmosphere in the home is very relaxed and there is natural and good engagement between staff and residents. Some residents have limited responses and although responses may not be clear to strangers, staff have excellent interpretive skills with residents. There are reported to be 592 staffing hours per week, although this was not calculated/verified from the staffing rotas. There are 3 staff on duty from 7.30 am and a further 2 from 9.00 am. In the afternoon/evening there are usually 4 staff on duty, although there is some flexibility about staffing times to match resident need. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 21 Staff training is good. All staff have received statutory training and appropriate updates. Training in the past year has included: Induction for new staff, POVA training, First Aid, Food Hygiene, Medication, Moving & Handling, minimising confrontation, NVQ, Autism and Healthy Eating. A course in ageing and dementia is presently being sourced. Two staff files were seen. One indicated concern that appropriate checks had not been carried out. Work in a previous placement had been without CRB and has still not been produced/seen. The Manager will pursue the details and concerns discussed – but it is a requirement of this report that evidence will be forwarded to the Commission indicating the suitability of a member of staff to work in this service setting including evidence of a satisfactory CRB check. Recruitment files were not available at the time of the last inspection and a requirement made that they must be available for all staff working in the home. Records relating to supervision of staff were seen and had been undertaken at least bi-monthly. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 22 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 good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run. There is positive leadership and an open management style. The home is run in the best interests of residents. Regulation 26 visits must be adequately recorded. EVIDENCE: The Manager is a qualified nurse and has the required experience to run the home. She impresses as a competent manager, open and transparent and demonstrated her knowledge and skills in management throughout the inspection. She was able to discuss any questionable or contentious issues in an open and professional way without the need to be defensive about the service. She was open to discussion and suggestion. There is a good an open dialogue between the Manager, staff and residents. The interests of residents were at the forefront of all discussions during the Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 23 inspection. All staff on duty were helpful during the process and made a valuable contribution to the inspection. Financial records were not inspected on this visit. At the time of the last inspection there were gaps in the regulation 26 visits and a requirement was made. The home is owned by Accord Housing Association but staffed and managed by the South Birmingham Care Trust. There have been regular visits by Accord on an almost monthly basis. Although at least monthly visits are reported to be carried out by a manager of the trust, no reports are completed or available in the home. The recent agreement was that these would be provided on a monthly basis by the Trust and that quarterly visits would be made by Accord. The reverse appears to have happened. All staff have completed the basic first aid training course and some involved in an advanced course. Fire records were seen and all checks and servicing of equipment had been carried out and fire drills arranged including involvement of residents. It was pleasing to see that individual assessments had been provided for all residents in relation to their capacity to respond to the fire alarm sounding. The Manager intends to carry out a fire drill at night time to test the efficiency of an evacuation. A fire risk assessment has been completed and updated as needed. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 x 3 3 4 x 5 2 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 3 26 2 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 x 3 2 3 x Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2 3 Standard YA1 YA1 YA20 Regulation Schedule 4(8) Requirement Timescale for action 31/12/06 31/12/06 28/11/06 4 5 6 7 8 YA24 YA24 YA26 YA26 YA34 9 YA41 Service Users Guide must include fees charged, what they cover & costs of extras 4(1) 5(1) Statement of Purpose & Service Users Guide require updating 13(2) Clear records must be kept when PRN medication is given including signatures, times & reasons 23(2)(b)(d) Carpet in hallway should be replaced. Previous timescale not met. 23(2)(b) Re-plastering of wall area required adjoining front entrance door. 23(2)(b)(d) Lino floor in 1 bedroom must be replaced with carpet. Previous timescale not met. 23(2)(b)(d) Replacement furniture required in ground floor bedroom identified 19(1) Suitability of staff member to work in the service to be reviewed and evidence forwarded to the Commission of satisfactory CRB 26 Regulation 26 visits must be undertaken monthly and record maintained in the home. Previous timescale not met 31/01/07 31/01/07 31/01/07 31/01/07 31/12/06 28/11/06 Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA24 YA6 Good Practice Recommendations Review need for key pad security on main entrance door It is recommended that goals set at service users meetings be kept under review to ensure they are met. Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 27 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 Albert Road (8b) (Hightrees) DS0000016966.V321557.R01.S.doc Version 5.2 Page 28 - 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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