CARE HOME ADULTS 18-65
Alvechurch Road (76) West Heath Birmingham West Midlands B31 3QW Lead Inspector
Gerard Hammond Unannounced Inspection 2nd February 2006 10:50 Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Alvechurch Road (76) Address West Heath Birmingham West Midlands B31 3QW 0121 258 0887 0121 258 0887 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.V283163.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 17th August 2005 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. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection visit in the current year and was unannounced. This report should be read in conjunction with the one written following the inspection carried out on 17 August 2005. Direct observation and sampling of records (including personal files, care plans, previous inspection reports safety records and other documents) were undertaken for the purposes of compiling this report. The Inspector met with all of the residents during the course of the visit. The Manager was formally interviewed and three other staff members spoken with informally. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
The newly appointed Manager has now been able to take up her post. In the relatively short time since appointment, she has actively sought to meet requirements made at the last inspection. A Statement of Purpose and Service User Guide have now been produced. Work has been begun towards improving information management by archiving files to make them more accessible, and to develop care planning and risk assessing. Regular key worker meetings have been started to help support this process, and a new system put in place for reviewing plans and individual goals.
Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 6 Formal staff supervision is improving since the Manager came into post. New handrails have been fitted in the house and in the garden to support residents in maintaining their mobility and independence. 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. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 Information required by prospective users of this service is now available. Residents’ needs and aspirations are assessed, but the admissions policy should make it explicit that this is required prior to placement. Prospective residents are given opportunities to visit and to stay at the home, prior to any decision about placement. All residents must be provided with copies of their individual contracts, which should be current and compliant with Standard 5. EVIDENCE: There have been no admissions since the last inspection visit, but a prospective resident is currently being introduced to the home. A Statement of Purpose and Service User Guide are now in place, as previously required. Discussions with the Manager and documents seen provided evidence of good practice with regards to the process being followed to introduce the prospective new resident. He is already known to other people in the house, and has had opportunities to visit and also to stay over. Appropriate assessment information is being gathered to inform future care planning, as appropriate. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 9 A requirement was made at the last inspection that the admissions policy should be amended to reflect current practice (i.e. that no-one is admitted without a full assessment of needs). The Manager advised that the policy is currently under review. A draft contract was seen for the prospective new resident, but a requirement that all residents should have a copy of their individual contracts in accordance with National Minimum Standard 5.2 remains outstanding. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Residents’ needs are reflected in their care plans, which require continuing development to include their goals and aspirations. Residents’ independence is encouraged through responsible risk taking, but risk assessments are in need of further development. EVIDENCE: Key Standards 6, 7 and 9 were all assessed at the last inspection. Standard 7 was met in full, and Standards 6 and 9 partially met. The current Manager took up her post in November 2005 and since then has sought to address issues raised in the last inspection report. Work has begun on archiving files with a view to making records current and more manageable. There is evidence of development of care planning and efforts being made to incorporate person-centred approaches into general practice. A new review format is being introduced, and individual residents now have a monthly meeting with key workers to discuss current issues. Written records are kept of these meetings. All of these developments are positive, and this work should be commended.
Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 11 Efforts are being made to develop care planning and risk assessing, as identified at the last inspection, and this continues to be a work in progress. Individual plans are still in need of work to include specific goals with measurable outcomes, as previously indicated. The Manager indicated that it is her intention to address this as each person’s plan is reviewed, and that information being gained in key worker meetings will be used to inform this process. Issues relating to risk assessments (including the need to cross reference with care plans, to identify hazards correctly and to ensure that control measures are incorporated into individual plans) are also being addressed, and it should be acknowledged that the Manager has not had a great deal of time to deal with these matters since taking up her post. This will be more fully assessed at the next inspection. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement. EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the time of the last inspection and met in full. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Support is given in accordance with residents’ needs and preferences. EVIDENCE: Key Standards 18, 19 and 20 were all assessed at the last inspection and fully met. The Inspector met all of the residents during the course of the visit. Individuals’ attire and personal grooming provided evidence that they had all been well supported in basic personal care. Interactions between residents and members of the care team were relaxed, warm and friendly, and appropriately respectful. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 14 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): No judgement. EVIDENCE: Key Standards 22 and 23 were assessed and met in full at the time of the last inspection. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 15 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): 27, 30 Some work is required to ensure that bathroom facilities meet residents’ needs appropriately. The home is clean, with a good standard of hygiene maintained. EVIDENCE: Key Standards 24 and 30 were assessed at the last inspection. As previously observed, there is a comfortable, homely and “lived in” feel about the shared spaces in the house and individual rooms are very personal to the occupants. Some issues were identified at the last inspection as needing attention. The kitchen is in need of substantial refurbishment. The Organisation has recognised this and plans to carry out work in the new financial year. Problems identified in the downstairs shower room have yet to be addressed, but the Manager was able to show that the property services team are scheduled to survey this shortly. It was noted that the temperature in both this room and the separate downstairs toilet was distinctly low on the day of the inspection visit, and an immediate requirement was made to rectify this. It is also required that CSCI be informed of the outcome of the property services team’s investigation, and of the action proposed to deal with this.
Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 16 It was noted that the wooden handrails in the garden outside the kitchen door have now been replaced as previously required. An additional handrail has also been fitted on the main staircase, to help support residents’ independent access. General standards of hygiene throughout the home are good, and the house is kept clean, warm and tidy. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 17 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 A competent and qualified staff team supports the residents. General recruitment policy and practice promotes residents’ protection. A current training and development plan is required to assess fully staff training needs. Staff are generally well supported, and formal supervision is improving. EVIDENCE: Staff records were sample checked. Information contained in the Statement of Purpose indicates that four members of the staff team are qualified to NVQ level 2; one of these is currently working towards NVQ level 3 and holds D32/3 Assessor’s Award, while another is working towards gaining this also. Two other staff members are working towards NVQ level 2 and have completed Learning Disability Awards Framework (LDAF) training: two further staff are currently also working towards completing LDAF training. There is a clear commitment within the Organisation and the staff team to ensure that people are appropriately trained. In order to assess this fully, a current staff training and development plan is required. This should indicate, for each person working in the home, all training completed and qualifications
Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 18 gained. Any gaps, including refreshers, should be highlighted, and the plan should show when outstanding training is scheduled and who is to deliver it. Records relating to recruitment of staff were generally satisfactory, and documentation required by regulation held appropriately. However, as previously noted, staff files sampled did not include a recent photograph and this is required. Records of formal supervision were not up to the required standard of six times in any 12-month period (pro-rata for part time staff). However, it should be acknowledged that the Manager has clearly sought to address this since coming into post, and it is anticipated that this standard will be met in the near future. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 19 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, 41, 42 The Home is generally well run, but some issues required by regulation need to be attended to. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: Key Standards 39 and 42 were assessed at the last inspection and met in full on that occasion. The Manager is qualified to NVQ level 4 and is hoping to begin study for the Registered Manager’s Award shortly. She holds a Diploma in Care Management Services and the D32/3 NVQ Assessor’s Award. She has demonstrated a positive attitude towards developing the service for the benefit of the people living in the house since taking up her post. It is required that an application to register the Manager should now be submitted to CSCI. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 20 It was noted that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) is falling short of the necessary standard, and this must be addressed. Visits must take place at least once a month and be unannounced. Written reports must be made for each visit and be made available to the Manager and also CSCI. It should be acknowledged that the Manager was very positive about the degree and quality of the support available to her from within the Organisation in general, and her line Manager in particular. Safety records were sample checked. Tests of the fire alarm and emergency lighting systems are generally being carried out, though it was noted that there were two gaps in recording in the period since November 2005. Firefighting equipment has been serviced recently. Fridge and freezer temperatures, and water outlet temperatures have been tested as required, and records kept appropriately. Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 2 X X X 2 3 X Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 22 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 Timescale for action 31/03/06 2. YA5 5(b-c) 17(2) Sch4(8) 3. YA6 15(1-2) 4. YA9 13(4) 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. Provide each resident with a 31/03/06 copy of the current contract, which should contain all the information indicated in Standard 5.2. Outstanding since 31 October 2005. Develop individual care plans 30/04/06 to incorporate goals, as identified in the main body of this report. Goals should be evaluated at reviews, which should take place at least every six months. Written records should be kept, indicating who takes part and how decisions are made. (Partially met) Risk assessments should be 30/04/06 developed as indicated in the main body of this report, and directly cross-referenced to
DS0000016934.V283163.R01.S.doc Version 5.1 Page 23 Alvechurch Road (76) 5. 6. YA24 YA27 23(2) 23(2) 7. YA34 19(4b) Sch2(1) 8. YA35 18(1c) 9. YA36 18(2) 10. 11. YA37 YA41 8 9 26 the care plan(s) to which they relate. Implement plans to refurbish the kitchen. Advise CSCI of the outcome of the property services team’s assessment of the downstairs shower room, and of proposed action. Ensure that a recent photograph of each person working at the home is filed with his or her personal records. Forward a current training and development plan (as detailed in the main body of this report) to CSCI. Ensure that each member of staff is formally supervised at least six times in any 12month period (pro rata for part-time staff) and maintain written records of such meetings. Submit a completed application to register the Manager to CSCI. The Organisation must ensure that unannounced visits required under Regulation 26 (Care Homes Regulations 2001) are carried out at least once a month, with written reports being made available to the Manager and to CSCI. 31/05/05 31/03/06 30/04/06 30/04/06 30/04/06 30/04/06 31/03/06 Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 24 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 YA6 Good Practice Recommendations Organise residents personal files so as to make essential information readily and easily accessible. Make positive use of indices and cross-references, and archive or dispose of material that is not current. Consider ways in which residents can be more actively involved in developing their own care plans. (Partially met) Alvechurch Road (76) DS0000016934.V283163.R01.S.doc Version 5.1 Page 25 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
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