Inspection on 25/04/07 for Bevis House

This inspection was carried out on 25th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bevis House 09/06/08

Bevis House 08/06/06

Bevis House 22/11/05

Bevis House 29/07/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Bevis House 5 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF Lead Inspector Sarah Bennett Key Unannounced Inspection 25th April 2007 09:50 Bevis House DS0000062630.V335203.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 Bevis House DS0000062630.V335203.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. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bevis House Address 5 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 444 2184 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) South Birmingham Primary Care Trust Family Housing Association Limited Mrs Dorothy Margaret Fisher Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate six people with a learning disability under 65 years. 6th December 2006 Date of last inspection Brief Description of the Service: Bevis House was purpose built as a care home, on the site of what was previously Monyhull Hospital. It was previously registered as one of a cluster of six homes. South Birmingham Primary Care (NHS) Trust manages the staff and the home and Family Housing Association owns the premises. At present the home accommodates five men. The men all have a Learning Disability, some have impaired mobility, and some have some behaviours that challenge. The accommodation comprises of six single bedrooms, a communal lounge, dining room, a W.C, supported bathroom, shower room, kitchen and laundry room. The home has a garden at the rear, with garden furniture and shade. The CSCI inspection report is available in the home for visitors who wish to read it. The current scale of charges for the home is £1511.95 per week. The fees payable to Family Housing Association are £127.35 per week. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. This unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2007 to 2008. The staff on duty and the people who live in the home were spoken with. Conversations with some people were limited due to their complex needs and limited verbal communication. Therefore time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: The people who live in the home are well supported with their personal care so they looked fresh and clean. Their clothes were of good quality and suitable to the weather and the activities they were doing. Staff regularly do the health and safety checks to make sure that it is a safe place to live in. People are supported to have regular health checks and when needed are referred to health professionals to ensure that their needs are met. Care plans showed how staff would support individual’s to meet their goals and aspirations. Risk assessments were detailed and stated how the risks to people living in the home are to be reduced as much as possible. Staff support people to go out often. A record of whether a person enjoys an activity or not is kept so that they don’t have to keep doing an activity that they don’t like. A variety of food is offered and fresh fruit and vegetables are available so that people can have a healthy diet. The home is well decorated and furnished so it is a comfortable and homely place to live. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There must be enough staff on duty at all times so that people can take part in meaningful activities. Records of individual’s health must be kept so that their health needs are well met and action can be taken soon if they are unwell. A regular audit of all medication should be done so that people always have the medication they need at the right time. Staff should allow individual’s to change their minds about what they want to do or eat so they choose what they do. The furniture should be suitable for all the people who live in the home so that they are comfortable. Pictures in bedrooms should be put back on the walls after the redecoration so that nobody hurts themselves, as they could be broken easily. Staff should be kept up to date with what is happening in the home and how they need to support the people that live there. The quality assurance system should be used and reports of Provider visits should be available so that it is clear that the views of the people who live there and their representatives are considered. All staff must know about fire safety so they can keep the people who live there safe. Bevis House DS0000062630.V335203.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. The summary of this inspection report can be made available in other formats on request. Bevis House DS0000062630.V335203.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 Bevis House DS0000062630.V335203.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): 1 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make a decision about whether or not they want to live at the home EVIDENCE: Records of the people who live in the home sampled included a service users guide to the home. They included all the relevant and required information to meet this standard. They were produced using pictures making them easier to understand. There are five people living at the home so there is one vacancy. Staff said that the Social Care Manager is dealing with referrals for this but there are no visits planned for anyone to visit. There have been no residents admitted for several years therefore the standard relating to assessment was not assessed at this visit. Bevis House DS0000062630.V335203.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): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information for staff is provided in care plans so that they know how to support individuals to meet their needs and achieve their goals. The people who live in the home are offered choices but improvement is needed to ensure they have choice in their day-to-day lives. The people who live in the home are supported to take risks within a risk assessment framework to ensure their safety. EVIDENCE: Records sampled included individual care plans. These were produced using pictures making them easier to understand and were person centred. They stated the things that the person likes and dislikes. Care plans stated how staff are to support the person with their health needs, personal care, during the night, medication, behaviour, communication, meals and diet, mobility, contact with their family and friends, hobbies and interests, sexuality, decision making, religion and culture, finances and going on holiday. Care plans sampled had been regularly reviewed. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 11 One care plan sampled included a social dictionary for the person that detailed how he communicates various things including his healthcare needs, what meals he wants to eat and his hobbies and interests. The minutes of a staff meeting in March 2007 stated that the manager had noted that meetings with the people who live in the home had not taken place since before she was absent due to sickness. Staff said that a meeting had been booked and this was recorded in the diary. There had been some individual meetings and minutes of these showed that staff asked people what activities they would like to do, where they would like to go on holiday and had spent time explaining to them their service users guide so they know what the home offers them. Staff spoken with said that they do not feel that on a day-to-day basis the people who live there have the opportunity to change their mind about what they want to do or what they want to eat as they are expected to stick rigidly to individuals activity plans and the menus. One staff supervision record sampled also stated this and felt this impacted on individual’s rights to choose what they do. Although it is important to plan activities and menus so that food can be bought, people have some plan to their day to motivate them and staffing can be organised, there should be some flexibility to ensure individuals can make different choices if they want to. The only restrictions placed on individuals are to ensure their safety and these have been placed following risk assessment. They are the locked front door, hazardous products locked in cupboards and the laundry, boiler room and store cupboard are locked. Records sampled included individual risk assessments that stated how staff are to support the person to minimise the risks involved with their epilepsy, if there is a fire, using knives and the kitchen, hot drinks and meals, bathing and showering, support during the night, locked front door, hazardous substances, car travel, hot weather, inappropriate behaviours, falls, being assaulted by other people living in the home and making allegations about staff. Bevis House DS0000062630.V335203.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. J UDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are not sufficient to ensure that people experience a meaningful lifestyle. The people who live in the home are offered a healthy and varied diet that meets their cultural needs. EVIDENCE: Records sampled showed that individuals enjoy watching football matches on TV. Staff had supported an individual to go to matches but the person was not interested in the match. However, they did like going to the club shop and buying a shirt and scarf so they now just visit the shop when they want to. Records sampled showed that people go to the day centre, for walks, watch TV, go shopping, go for a drive, go to parks, out for lunch, have massage therapy, go to a local lunch club, play games, go to church, have a foot spa, listen to music, go to a local café for a drink and go to the cinema. Records included whether or not the person enjoyed the activity. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 13 Some records sampled stated that activities did not take place, as there were insufficient staff. One person was ready to go to the day centre and had to wait from 9.50am – 11.10am as two other people needed support to go to the GP and there were only four staff on duty until an agency member of staff came in at lunchtime. Previous notifications to the CSCI have suggested that minimum staffing levels had not been met which had affected individual’s activities. The inspector met with the Provider, Family Housing Association regarding concerns about this. They have confirmed that they are working with the Trust to ensure that the staffing levels that are required to meet the needs of people are met. Staff said that often activities are rushed and people are rushed in and out just so it can be recorded that lots of activities had been done. People were observed going for short walks and it was not always clear what the purpose of these walks were. Staff said and minutes of meetings stated that they hope to arrange holidays for all the people living in the home this year, one person said he wants to go to Weston and another person said they want to go to Spain. Staff said that the vehicle provided is a large car not a minibus, as one person who does not like steps found this difficult to access. Staff said that some of the other people have difficulty getting in and out of the car. Staff said that one person needs 2:1 staff support to go out in the car and only one other person can go out with him as they don’t aggravate each other so it is safe. Unless they are well staffed so there are three staff and two people in the car. It is essential that individual risk assessments be followed when using the car so that staff are not expected to put themselves and the people living there at risk. Records sampled showed and people said that they keep in contact with their family and friends where this is appropriate by visiting them or them visiting the home. Records sampled showed that staff had tried to make contact with relatives where there had not been contact for some time. Records sampled showed and it was observed that people are involved in doing their laundry, making their breakfast and cleaning their bedroom. The menu stated that lunch was beans on toast, one person had soup, as they preferred this. The people living in the home were involved in preparing lunch and staff sat with them to eat so making it a social occasion. There were a choice of cold drinks and sauces on the table. Food records sampled showed that a variety of food is offered that reflected the cultural background of individuals. Fruit and vegetables and low fat options were included in the menus and food records on each day, so encouraging healthy eating. People were observed eating fruit for snacks when they wanted them. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the personal care needs of people living in the home are met but arrangements are not always sufficient to meet individual’s health needs. The management of the medication does not always protect the people who live there and ensure they receive their prescribed medication. EVIDENCE: The people living in the home were dressed appropriately to their age, gender and activities they were doing. One person was wearing a football shirt of their favourite football team. One persons care plan stated that they go to church weekly and like to get dressed up. It detailed what the person likes to wear to church. Throughout the day staff supported people to change their clothes and wipe their mouths where needed after meals and before going out. Records sampled included individual moving and handling assessments stating how staff are to support individuals with their mobility and what to do if they should fall. Where appropriate some people had eating and drinking guidelines. These had been developed by the Speech and Language Therapist for staff to follow to ensure that the person does not choke. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 15 Records showed that where appropriate health professionals are involved in the care of individuals. Where individual’s health needs have changed staff had ensured that referrals to professionals were made and staff requested that appointments were brought forward. Records included individual Health Action Plans. These are personal plans about what a person needs to stay healthy and what healthcare services they need to access. They were produced using pictures making them easier to understand. Records sampled showed that individuals have regular check ups with the dentist and optician and visit the chiropodist where needed. The people living in the home are weighed regularly and where appropriate they are referred to the Dietician. For one person the Dietician suggested that staff have healthy eating training and some staff have had this. Menus showed that low fat options are offered. The Dietician also suggested that the person have more exercise and take part in the Walk 2000 programme. Records showed that staff support the individual to do this when there are enough staff on duty. One person’s records showed that there had been concerns about their irregular bowel habits. Health professionals were involved and appropriate referrals had been made. However, staff had not completed bowel charts for the individual. In April 2007 there were seven days when no record was made as to whether the person had a bowel movement or not. In March 2007 there was no record on twelve days and in February 2007 there was no record on thirteen days. From 5th to 18th February either there was no record made or it stated that the person had not had a bowel movement but there was no record of action being taken to ensure their well - being. Records must be kept to ensure that health professionals can investigate concerns about the person’s health and have the information they need to do this. Medication is kept in a locked cabinet. Boots supply individual’s medication using the monitored dosage system when the medication can be stored in this way. Where people were prescribed PRN (as required) medication protocols were in place that stated when and why the medication should be given. Five members of staff have received medication training and been assessed as competent to administer medication. The monitored dosage pack for one person’s nighttime medication still had a tablet in it where staff had signed the Medication Administration Record (MAR) to say that it had been given. Staff said that they do audits of medication that is in boxes but not of the blister packs. It is recommended that these are included in the audits to ensure that people receive their prescribed medication. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 16 Records showed that staff had spent time with individuals and their relatives where appropriate to discuss their wishes when they die. Their wishes had been detailed in their records so that if this happens staff will be able to ensure that their final wishes are followed. Bevis House DS0000062630.V335203.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the views of the people living in the home are listened to and acted on. Arrangements are in place to ensure that individuals are protected from abuse. EVIDENCE: There had been no complaints made to the CSCI or recorded in the home’s complaint record since the last key inspection. The Service Users Guide to the home included the complaints procedure in picture format making it easier to understand. Records stated that staff had spent time with individuals explaining to them the complaints procedure. Records sampled included an inventory of the person’s belongings. These had been updated when they had bought new things or thrown things away with the reason why they needed to be disposed of. The personal finance records of two people living in the home were looked at. The money kept in individual wallets cross-referenced to their record. Records included when money was paid in and when money was withdrawn. Records showed that individuals regularly paid their rent so that they were not at risk of building up rent arrears. Records showed that people spent their money on personal items and not on things that should be provided as part of their fees. Receipts were available of all purchases. Some of the people living at the home have behaviours that can be difficult. Reactive strategies were in place that stated how staff are to respond to and manage individual’s behaviours. One person’s strategy stated that it was Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 18 important that staff followed it to reduce the individual’s anxiety. Where necessary staff use Studio III techniques of physical intervention to manage individuals’ behaviours. Staff said that updated in-house training had been booked for all staff to attend to ensure they are aware of the techniques to use. Staff training records sampled showed that staff had received training in adult protection and the prevention of abuse. Bevis House DS0000062630.V335203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is homely, comfortable and safe for the people who live there. EVIDENCE: The communal rooms were well decorated and furnished. There were pictures around the walls making it homely. Bedrooms had been redecorated to a good standard and to individual tastes and interests. Staff said that individuals were involved in choosing the colours of their bedrooms. Bedrooms contained personal possessions and pictures. However, these had not been put back up since redecoration, which could be a hazard to some people, as they may get broken. Putting the pictures back up will also make the rooms look better and finish the redecoration. The doorframes around two of the bedrooms had been re - plastered in places as people slam the door but the plaster had not been repainted so this looked unfinished. Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 20 One person was observed having difficulty getting up from the sofa in the lounge. An audit should be completed to ensure that the furniture is suitable for all the people living in the home. Where it is identified that it is not suitable appropriate aids and adaptations should be purchased. The home was clean throughout and free from offensive odours. Hand wash, hand towels and toilet rolls were provided in all toilets and bathrooms to minimise the risk of cross infection. Bevis House DS0000062630.V335203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development are variable, which can impact on staff’s ability to meet individual’s needs. EVIDENCE: Over 50 of staff have National Vocational Qualification (NVQ) level 2 or above in care which meets this standard. Records showed that when staff started working at the home they received an induction so that they knew what their role was. Staff also undertake the Learning Disability Award Framework (LDAF) training so that they understand and have the skills to meet the needs of people who have a learning disability. There were four staff on duty in the morning, the senior was ringing the bank and agency to bring the staff numbers up to the minimum level of five to meet the needs of individuals. Staff said that there had been five staff on most shifts recently. An agency member of staff who had not worked there before arrived at 12 noon. Staff said that there were also agency staff working the day before. Some agency staff had not worked at the home before and staff felt that they are often used just to make up the numbers. Staff said there is not an incentive for them to work bank shifts at weekends, as they do not get the enhancements paid that they would usually get and they are paid less per hour Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 22 when they do bank work. Rotas showed that in the last two weeks there were five staff on most shifts during the day and two staff at night. However, bank and agency staff had been used to maintain these levels. Staff said that one member of staff started a few days before and that the home is now fully staffed. Staff meeting minutes showed that there had been four meetings in the last year. This does not meet the standard of at least six meetings each year. Regular staff meetings should take place so that staff are kept up to date with individual’s needs and how they are to support them. Staff records sampled included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken. This ensures that suitable people are employed to work at the home. Records sampled showed that staff had received training in moving and handling, first aid, food hygiene, epilepsy, autism, fire safety, medication, the Protection of Vulnerable Adults (POVA), healthy eating and Studio III (a technique of physical intervention). Some staff had an update in fire safety the week before. The senior said that those who did not attend would be going to other homes to have this training but there was not a date set for this. Staff records sampled showed that staff had received regular, formal supervision with a senior or the manager to monitor their performance and to ensure they know how to meet individual needs. Bevis House DS0000062630.V335203.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements are sufficient to ensure that the people who live there benefit from a well run home. The people who live there and their representatives cannot be confident that their views always underpin all selfmonitoring, review and development by the home. Arrangements are generally sufficient to ensure the health, safety and welfare of the people living in the home. EVIDENCE: Staff said that the manager has not been there often in the last year because of sickness and annual leave. Staff said that the seniors do most of the management tasks. The evidence from this and the previous visit show that despite the absence of the manager improvements have been made and the systems are in place to ensure better outcomes for the people who live there. Staff said that a representative of the Provider, Family Housing Association visits monthly as required under Regulation 26. There were only available Bevis House DS0000062630.V335203.R01.S.doc Version 5.2 Page 24 reports of three of these visits. They included the views of the people who live there and staff. All reports should be available so that staff can ensure that any improvements noted are made to make it a better place to live. The Social Care Manager from the Trust visits monthly to do an audit. Residents records sampled showed that the views of the people who live there had been considered. One person responded positively to being asked if he liked the home, food and the staff. South Birmingham Primary Care Trust have a quality assurance system but there was no evidence that this system had been used. Staff are doing the ASSET Health and Safety distance learning course and their tutor visited them during the day to discuss their progress. A Corgi registered engineer tested the gas equipment in March 2007 and stated that it was safe to use. Fire records showed that staff test the fire alarm weekly and the emergency lighting monthly to make sure they are working. There was a fire drill in February 2007, the last fire drill before that was in July 2006. Fire drills should be held at least every six months to make sure that all residents and staff know what to do if there is a fire. Five members of staff attended a fire lecture the previous week. It was not clear from sampling records when staff had previously had this training so all staff need to receive this so that they are aware of safe practice to minimise the risk of fire. Each person had a fire risk assessment so that staff are aware of the risks to individuals and how these are to be minimised. Staff test the water temperatures weekly to make sure they are not too hot or cold so that people can wash comfortably. The record of the last test stated that temperatures ranged from 41 – 44.4 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. Where temperatures were recorded as too hot or too cold records showed that the maintenance team were contacted to rectify them. Bevis House DS0000062630.V335203.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 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X X 2 X Version 5.2 Page 26 3 2 2 3 Bevis House DS0000062630.V335203.R01.S.doc 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 YA12 Regulation 18 (1) (a) Requirement Timescale for action 30/06/07 2. YA19 12 (1) (a) 3. YA42 23 (4) (d) Minimum staffing levels must be maintained at all times to enable people to take part in meaningful activities. Records of the bowel movements 31/05/07 of people living at the home must be kept where appropriate to ensure their well –being and their health needs are met. (Outstanding since last inspection). Suitable arrangements must be 31/08/07 made for all staff to receive training in fire safety to ensure the safety of the people who live at the home. Bevis House DS0000062630.V335203.R01.S.doc 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. 4. 5. Refer to Standard YA7 YA20 YA26 YA29 YA33 Good Practice Recommendations Staff should support individuals to make decisions and choices whilst acknowledging that they may change their minds and make alternative choices. Medication in blister packs should be included in the regular medication audits to ensure that people receive their prescribed medication. Pictures should be put back up in bedrooms so that the redecoration is finished and people will not be at risk of pictures being broken that may hurt them. An audit should be completed of the furniture in communal rooms to make sure it is suitable for all the people who live there. There should be at least six staff meetings a year and minutes of these should be kept. This will ensure that staff are informed of individual’s needs and how they are to support them. Reports of the monthly visits by the Provider should be available in the home so that staff know what they need to do to improve the home. The quality assurance system should be used and action taken to improve the lives of the people who live there. 6. 7. YA39 YA39 Bevis House DS0000062630.V335203.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: 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. 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