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Inspection on 19/07/06 for Alvechurch Road, 76

Also see our care home review for Alvechurch Road, 76 for more information

This inspection was carried out on 19th July 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides good information and opportunities for prospective residents to help them make a decision about whether or not to seek a placement. People`s needs are appropriately assessed, and they have the chance to come and stay, so that they can see for themselves if the service offered is what they want. Staff treat the people living in the house with warmth and respect, and make sure that they get a good standard of basic personal care, according to their needs. Residents enjoy a house that is comfortable, homely and feels "lived in". People are encouraged to be as independent as their personal capabilities allow, and staff try hard to involve residents in all aspects of life in the house. Residents are well supported to keep in touch with families, friends and loved ones, both at home and away from the house. People living in the house have opportunities to pursue valued activities, and to be part of the local community. Care plans are kept under constant review through regular key worker meetings. Good use of "read and sign" sheets helps to ensure that staff keep up to date with important information. People are supported to be healthy by accessing primary and specialist healthcare services according to their needs, and by being encouraged to take responsibility for their diets. They enjoy their food and have access to a diet that is varied and nutritious. Good practice in the storage, handling and administration of medicines in the home ensures people get the right medication at the right time.

What has improved since the last inspection?

Clear efforts have been made by the Manager and staff team to meet requirements and to develop the service, since the last inspection. Residents now have up to date written contracts, as required. Care plans have been developed to include people`s goals, and these are being kept under review, as appropriate. There is clear evidence of the development of person-centred approaches in care planning and management, notably in the introduction of new Health Action Plans. Residents` group meetings are now facilitated by an independent person, and one of the residents acts as the secretary and looks after the records. Residents now play an active role in carrying out health and safety checks around the home, so as to give them a greater sense of ownership and to promote their independence. One resident in particular has been actively supported to improve her activity opportunities, with notable success. Formal supervision of staff has continued to improve, and is now up to the required standard. Visits and reporting required under Regulation 26 (Care Homes Regulations 2001) has improved since the last inspection.

What the care home could do better:

There is an outstanding requirement that the admissions policy be updated, so that it reflects actual practice. It is recommended that the "read and sign" sheet for the missing persons` policy is updated. Staff should remember to dispose of cigarette ends appropriately if they go into the garden to smoke. Health and safety must be improved by ensuring secure storage of COSHH products and regular testing of fridge and freezer temperatures. The Manager should submit a completed application to be registered with CSCI.

CARE HOME ADULTS 18-65 Alvechurch Road (76) West Heath Birmingham West Midlands B31 3QW Lead Inspector Gerard Hammond Unannounced Inspection 19th July 2006 09:30 Alvechurch Road (76) DS0000016934.V299642.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 Alvechurch Road (76) DS0000016934.V299642.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. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alvechurch Road (76) Address West Heath Birmingham West Midlands B31 3QW 0121 258 0887 0121 475 8741 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) FCH Housing & Care Mr Griffith Hughes Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alvechurch Road (76) DS0000016934.V299642.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: 76 Alvechurch Road is registered to provide accommodation, care and support for up to six adults with learning disabilities. The house is a spacious domesticscale property located in the West Heath area of Birmingham, close to shops and local amenities, and well served by public transport. There is off-road parking at the front of the house. Accommodation is provided in single bedrooms, two on the ground floor and four on the first floor, which can be accessed either by the main staircase or by a passenger lift. Downstairs there is a good-sized lounge / dining room, kitchen and separate laundry. There is also an assisted shower room, with w.c. and wash hand basin, and a further separate w.c. Upstairs are two bathrooms (one assisted), both with w.c. and wash hand basins. The office is also situated on the first floor. To the rear of the property is a secure private garden, with a patio and seating area, and lawn edged with planted border. The current range of fees charged by this service is £326.44 - £743.19 per week. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was collated from a range of sources, including previous inspection reports, service history and the pre-inspection questionnaire completed by the Manager, prior to the home visit. Direct observation and sampling of records (including personal files, care plans, safety records and other documents) were also used for the purposes of compiling this report. The Inspector met all of the residents during the course of the visit. The Manager was formally interviewed and three other members of staff were also seen informally. The family of one resident was contacted by telephone. A tour of the building was also undertaken. What the service does well: The service provides good information and opportunities for prospective residents to help them make a decision about whether or not to seek a placement. People’s needs are appropriately assessed, and they have the chance to come and stay, so that they can see for themselves if the service offered is what they want. Staff treat the people living in the house with warmth and respect, and make sure that they get a good standard of basic personal care, according to their needs. Residents enjoy a house that is comfortable, homely and feels “lived in”. People are encouraged to be as independent as their personal capabilities allow, and staff try hard to involve residents in all aspects of life in the house. Residents are well supported to keep in touch with families, friends and loved ones, both at home and away from the house. People living in the house have opportunities to pursue valued activities, and to be part of the local community. Care plans are kept under constant review through regular key worker meetings. Good use of “read and sign” sheets helps to ensure that staff keep up to date with important information. People are supported to be healthy by accessing primary and specialist healthcare services according to their needs, and by being encouraged to take responsibility for their diets. They enjoy their food and have access to a diet that is varied and nutritious. Good practice in the storage, handling and administration of medicines in the home ensures people get the right medication at the right time. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is an outstanding requirement that the admissions policy be updated, so that it reflects actual practice. It is recommended that the “read and sign” sheet for the missing persons’ policy is updated. Staff should remember to dispose of cigarette ends appropriately if they go into the garden to smoke. Health and safety must be improved by ensuring secure storage of COSHH products and regular testing of fridge and freezer temperatures. The Manager should submit a completed application to be registered with CSCI. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 7 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. Alvechurch Road (76) DS0000016934.V299642.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 Alvechurch Road (76) DS0000016934.V299642.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and aspirations are assessed appropriately. Prospective residents are given opportunities to visit and stay at the home, prior to any decision about placement. Residents have individual written contracts, so that there is a clear agreement in place about the service being provided. EVIDENCE: One new resident has come to live in the house since the time of the last inspection. His personal file contained evidence of an appropriate action plan and timetable for introduction to the service. This provided him with opportunities to visit and stay over before making the decision to move. A detailed assessment and care plan are also in place as required. There is an outstanding requirement to update the admissions policy so that it explicitly states that a full assessment of individual needs should be completed prior to admission. The Manager advised that this has been referred to the organisation for amendment. However, the recent admission provides ample evidence that appropriate practice in this area is being followed. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 10 A requirement was also made at the last inspection that residents should all have individual contracts, as indicated by National Minimum Standard 5.2. It was noted that these are now in place. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect residents’ assessed needs, aspirations and personal goals so that it is clear how they should be supported and what they wish to achieve. Residents are consulted on and participate in all aspects of life in the home, in accordance with their individual wishes and capabilities. People’s independence is encouraged and supported through responsible risk taking. EVIDENCE: Sample checking of personal files provided clear evidence of progress in care plan development since the last inspection. Records contain detailed individual profiles, which provide good quality information about people’s preferences. Plans have been developed to extend goal setting and there is good use of “read & sign” sheets throughout, to ensure that staff keep up to date with changes. There is also evidence of the appropriate use of person-centred approaches. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 12 A new format has been put in place for monthly meetings between individuals and their key workers. These are designed to keep care plans under constant review and this is another example of good practice. The Manager also advised that residents have recently had reviews by social workers. Risk assessments are clearly linked to relevant care plans, and it is clear from conversations with the Manager that responsible risk taking is viewed positively, providing opportunities for learning and personal development. Two of the residents travel independently to day activities on public transport, following appropriate risk assessment and travel training. A recommendation was made that a risk assessment index would further support tracking. Residents were directly observed washing up and clearing the kitchen after their breakfast. They also proudly showed the Inspector their garden, and in particular the flowers and shrubs that they had bought and planted. It is clear that residents are actively encouraged to participate in things that need doing around the house, according to individual wishes and abilities, and enjoy it too. Staff were directly observed supporting one resident to make choices about what to wear (to take account of the very hot weather that day) and later on to get drinks and make choices about what to eat for lunch. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to pursue valued activities and to be a part of their local community. People are supported to maintain contact with families, friends and loved ones. Individual rights are respected, and people living in the house are encouraged to take responsibility, so as to enhance personal independence. Residents enjoy their food and have access to a varied, balanced and nutritious diet. EVIDENCE: Most residents access formal structured day care opportunities at local centres and colleges. One person has an Autistic Spectrum Disorder and prefers to access community facilities with the support of members of staff, as he does not cope well with unfamiliar places and people. Another resident has now Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 14 started accessing activities outside the home on a much more regular basis than previously, and said that she enjoys this very much. Information on personal records shows that people use local shops, clubs and pubs. Some go line dancing and to keep fit sessions. Others attend night school to do arts and crafts. One resident has a job working in a local charity shop. Residents are currently busy making holiday plans. Some are going to Minehead, while others are happier being able to go away on day trips. At home, residents enjoy watching TV and relaxing together, or sometimes listening to music or watching films in their own rooms. Records also show that residents are supported to keep in touch with families and friends on a regular basis. This includes visiting or staying at their parents’ homes, and also maintaining other longstanding friendships by visits or going out together, according to individual preferences. Residents are actively encouraged to take responsibility for things around the house, so as to enhance independence. Examples of this include a new practice that the Manager has recently introduced. Staff have been delegated responsibility for conducting regular health and safety checks around the home. Residents take an active part in this exercise, with the intention of reinforcing their sense of ownership and responsibility for the place in which they live. People who go out to day centres also take responsibility for preparing their own packed lunches, thereby encouraging independence and facilitating personal choice. Personal records include clear indications of individual food likes / dislikes. Records also show that residents have access to a varied and balanced diet, and are encouraged to eat healthily. The relatively small size of the home facilitates choice: residents reported that they are actively involved in shopping for and choosing food and can have things they like. One resident in particular reported that she is now trying hard to follow a healthy eating plan, and that she is very pleased with the results. Food stocks were examined: supplies were ample and included fresh produce. Alvechurch Road (76) DS0000016934.V299642.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in accordance with their individual needs and preferences. People’s healthcare needs are met appropriately, and they are protected by the home’s medication procedures and practice. EVIDENCE: As observed at previous inspections, interactions between residents and staff are relaxed, warm and friendly. People are clearly comfortable in each other’s company, and support is given with respect and patience. Individuals’ grooming and dress provided further evidence of good standards of basic personal care. Care records show input from the GP, dentist, chiropodist, optician, physiotherapist and OT, and provide evidence that appropriate referrals and follow up action is taken, according to individuals’ needs. Health Action Plans are being developed, introducing a good person-centred format (Essential Lifestyle Planning) that has also been seen in one of the organisation’s other homes. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 16 The care team have been very pro-active with one resident in particular since the last inspection, with notable success. She is now following an exercise programme, and taking responsibility for monitoring her own diet. As a result her activity levels have increased significantly and she is much more motivated than previously. She said “I’m much happier being active. I’m able to do things now, and I’m enjoying my exercise”. The Medication Administration Record (MAR) was sample checked and had been completed appropriately. There is a good system in place for minimising the risk of administration errors. The person on duty responsible for giving medication signs the MAR sheet: this is checked by a second person, who then signs a separate witness sheet. Other examples of good practice include a daily audit of all medication not stored in blister packs. Three residents’ medication stocks were randomly sampled and all were correctly accounted for. Creams and lotions were labelled with the date of opening, and all were in-date. Each resident’s medication record included a photograph, copies of prescriptions, protocols for PRN (“as required”) medication (recently updated and signed by the GP) and other supporting information. Practice in this area is very good. Alvechurch Road (76) DS0000016934.V299642.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents consider that their views are listened to and acted upon. General practice promotes the protection of residents from abuse, neglect and self-harm. EVIDENCE: These key standards have been consistently met at previous inspections. No complaints have been received in respect of this service since the last visit. As reported previously, an appropriate complaints procedure is in place. This is supported by a “postcard” system that residents can use should they wish to make a complaint. The card can be sent to senior managers outside the home, and an independent person sent in to investigate any issues, if required. Residents’ group meetings are held regularly, and facilitated by an independent person. None of the care team are present, unless specifically invited, so as to promote open comment and debate. This is now seen as an essential component of the home’s complaints procedure and quality assurance measures. One of the residents acts as Secretary and keeps the meeting records. Residents spoken to indicate that they knew they could complain and said they felt comfortable raising concerns with the Manager or members of staff. An appropriate Adult protection Policy is in place, but it was noted to be due for review. The policy is cross-referenced to Local Multi-Agency Guidelines and copy of this document filed with it. “Read and sign” sheets for these were in place. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 18 An appropriate Missing Persons Procedure is also in place – it is recommended that the “read and sign” sheet for this should be updated. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a house that is safe, comfortable, homely and welcoming. Steps have been taken to improve the situation in the downstairs shower room: toilets and bathrooms meet the needs of people living in the house. The home is clean and hygienic, with good standards of hygiene generally maintained. EVIDENCE: As previously reported, people living at Alvechurch Rd. enjoy a house that is welcoming, comfortable and feels “lived in”. Residents’ own rooms are individual in style, with personal effects and possessions in evidence throughout. The Manager advised that the kitchen refurbishment is scheduled for August and eagerly anticipated. She said that discussions had taken place with senior managers regarding previously identified problems in the downstairs shower Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 20 room, and it was hoped that a permanent solution to this could be found when financial resources allowed. In the interim, she has made arrangements for the shower room to be professionally cleaned each month, and taken steps to ensure that staff do all they can to ventilate the room (e.g. make sure extractor fan is clear of dust etc.) appropriately. The situation should be kept under review. Recent problems with the lift have been attended to, and it was working satisfactorily on the day of the visit. Reference was made earlier in this report to the pride that residents take in their garden. It was noted that an ashtray full of cigarette ends had been left on the wall by the back door. Members of staff taking cigarette breaks should at least ensure that this is emptied after use, and remember whose garden it is. This matter has been raised at a previous inspection. The house is kept clean and tidy, and a good standard of hygiene maintained throughout. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and appropriately qualified team of staff supports the people living in the house. Staff have opportunities for training and development, and are appropriately supervised. This means that residents are cared for by people who understand their needs and conduct themselves in an appropriately professional manner. Residents’ protection is promoted by robust recruitment procedures and practice. EVIDENCE: The staff team is appropriately qualified. Information provided in the preinspection questionnaire indicates that 75 of the staff team have NVQ level 2 qualifications or above. Members of the care team on duty on the day of the visit were clearly competent, giving support in a professional manner that provided evidence of their understanding of the needs of people with learning disabilities. Staff files sampled contained required documentation, and provided evidence of an appropriately robust recruitment procedure, backed up by practice. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 22 A requirement made at the time of the last inspection to provide an up to date training and development plan has been met. The organisation operates a rolling programme of training for staff, and issues are identified appropriately at supervision and appraisal meetings. Supervision records show that further improvements have taken place since the last inspection, and this is now up to the required standard. Staff team meetings are also generally held on a monthly basis. The residents have benefited from a relatively stable staff group, and a number of them have worked at the home for several years. The members of staff who were interviewed said that the team is supportive of each other and members generally get on well. One member of staff said “I enjoy coming to work”. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Alvechurch Road benefit from living in a home that is well run. Residents know that their views are taken into account appropriately and underpin service development. General practice promotes residents’ health, safety and welfare, but one or two issues require attention. EVIDENCE: The Manager is appropriately qualified. She presents very positively, and continues to be enthusiastic about developing the service for the benefit of the people living in the house. She paid tribute to her staff team, and also said that she felt well supported by her line manager. Members of staff report that she is approachable. She delegates appropriately and positively seeks opportunities for residents and staff to develop, as shown by some of the Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 24 things that she has introduced since taking up her post and indicated elsewhere in this report. She said “I’m happy to be here”. The mother of one of the residents told the Inspector that she was very happy with the way her son’s placement had been arranged and supported. She said she felt very comfortable contacting the Manager and staff at the home, and that they made her feel that “nothing was too much trouble”. There is an outstanding requirement that a completed application be submitted to register the Manager with CSCI, and this should now be dealt with as a matter of priority. Visits and reporting required under Regulation 26 (care Homes Regulations 2001) have improved since the last inspection, as required. As reported earlier, residents have regular group meetings, now facilitated by an independent person. This is seen to be an important link between residents and the wider organisation, in terms of providing another “vehicle” for monitoring service quality. Service users know that they can complain and who they can talk to. The organisation is very pro-active in promoting service users’ right to speak up and be heard. Safety records were sample checked. Monthly health and safety checks around the house are now done with residents’ involvement, as stated earlier. Reports are made to maintenance team, and signed off when completed. There were no requirements following a recent visit by the local Fire Officer. Fire risk assessments were in date, and fire drills have been held at monthly intervals. Fire-fighting equipment, and the emergency lighting and fire alarm systems have all been serviced. A weekly test of the fire alarm has been completed and written record kept as required. Portable Appliance Testing of electrical equipment has been done. Tests of water temps have been completed and recorded appropriately. Tests of the fridge and freezer have generally been done, but there were some gaps in recording. It was noted that the COSHH cupboard was unlocked. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1) Requirement The Admissions Policy should be developed to include an explicit statement to the effect that a full assessment of individual needs should be completed prior to admission. Outstanding since 31 October 2005. Implement plans to refurbish the kitchen. Review the outcome of measures taken to address problems in the downstairs shower room and take appropriate action, informing CSCI. Submit a completed application to register the Manager to CSCI. (Application received following visit to home) Ensure that the COSHH cupboard is kept secure at all times. Ensure that a test of the fridge and freezer temperature is completed daily, with a written record maintained. DS0000016934.V299642.R01.S.doc Timescale for action 30/09/06 2. 3. YA24 YA27 23(2) 23(2) 31/10/06 31/10/06 4. YA37 8 9 30/09/06 5. 6. YA42 YA42 13(4c) 13(4c) 30/08/06 30/08/06 Alvechurch Road (76) Version 5.2 Page 27 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 YA9 YA23 YA28 Good Practice Recommendations Make an index for the risk assessment section on residents’ personal files, to facilitate tracking. Update “read and sign” sheet on Missing Persons Policy, to ensure that all of the current staff team are familiar with correct procedure. Ensure that, if staff are smoking in the back garden, that they empty ashtrays after use. Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Alvechurch Road (76) DS0000016934.V299642.R01.S.doc Version 5.2 Page 29 - 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. 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