Inspection on 15/06/05 for 56-58 Carlton Road

This inspection was carried out on 15th June 2005.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56-58 Carlton Road 22/05/06

56-58 Carlton Road 19/12/05

56-58 Carlton Road 03/12/04

56-58 Carlton Road 14/06/04

56-58 Carlton Road 18/11/03

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

CARE HOME ADULTS 18-65 Carlton Road 56-58 Carlton Road Small Heath Birmingham B9 5EB Lead Inspector Brian Reamsbottom Unannounced 15 June 2005 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 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 Stationary 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. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carlton Road 56-58 Address 56-58 Carlton Road Small Heath Brimingham B9 5EB 0121 772 4078 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Arshad Mahmood Arshad Mahmood CRH 3 Category(ies) of Learning Disability (3) registration, with number of places Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 03 December 2004 Brief Description of the Service: 56 – 58 Carlton Road is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of three people with learning Disabilities. Service users have their own rooms situated on the first floor.The home is staffed 24 hours a day including a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for the service users. Service users are encouraged and supported to maintain links with their families and the local community. The care needs of the service users are monitored and reviewed and action is taken to address any concerns.The home is situated in the Small Heath area of Birmingham. It is close to local amenities and good transport links into the city. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected unannounced from 10.00 to 13.10. The documentation inspected included the following: Care plans, risk assessments, fire records, medication records, health and safety records, accident book, daily records, staff personal files and staff training records. Two service users were spoken to. This was limited due to the communication needs of the service users. Two members of staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 6 Offer new opportunities for service users to experience different activities both inside and outside the home. Introduce a health and safety audit to highlight issues that must be addressed as a high priority, for example, the restrictor to be refitted to the first floor bathroom window, remove the paper tissues from around the light fitting in the laundry, remove the screws from the wall in the laundry and list the taps that have been test for hot water temperatures. 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. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 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 standard(s) 1 and 2 The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services provided enabling an informed decision about living in the home. EVIDENCE: The Statement of Purpose and the Service User Guide have included the additional information required at the last inspection. The regulations are being met. There have been no new admissions for several years. The personal files inspected contained full assessments that included the views of service users. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6 7 and 9 The care plans had sufficient detail on how the individual needs of the service users were to be met and strategies for managing risks were clearly identified. EVIDENCE: Service users have a care plan. The plans are reviewed every six months or as needs change, they have goals agreed with timescales to enable service users meet their goals. The service users are involved in the reviews of the care plans, assisted by staff, relatives and social workers if needed. The care plans show that progress is being made by service users in gaining greater independence in their daily living. On talking to a member of staff and reading care plans in was apparent that service users decision making is listened to and acted on. The risk assessments for each service user are in place, they are relevant and up to date. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12 13 15 and 17 Service users have access to a range of opportunities to afford them a meaningful lifestyle. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 11 The staff group actively encourage service users to follow leisure activities of their choosing. Service users enjoy swimming. Use is made of the pool at the local leisure centre. Service users, who are unable to use the local pool for personal reasons, also use the pool at Brooklands hospital. Visits to shops, cinema, parks, pubs and restaurants are made. Service users would benefit from being offered new opportunities and challenges in their leisure activities. Records of what activities are offered and if refusals are made must be kept. Service users have keys to their bedroom doors; however, they choose not to use them. Service users were observed to have unrestricted access around the home and garden. There appeared to be a good rapport with service users and the staff group. The menus show that the food on offer is varied, wholesome and nutritious. The food that service users eat is recorded, however, the vegetables on offer must be recorded. Service users have use of the kitchen with supervision from the staff team, in preparing and cooking of meals. The main activity service users make use of the kitchen is for making snacks and drinks. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18 19 20 The medication management is good ensuring service users receive medication as prescribed. Systems are in place to ensure that service users receive the care they need. EVIDENCE: The care plans clearly show how service users personal care is to be given. Personal care was observed to be given behind closed doors, enhancing the service users privacy and dignity. Service users health care needs are attended to, and records of appointments and outcomes are maintained in service users files. The service users have Health Action Plans the staff team has developed these with input from GPs, Practice Nurses and Dentists. The professionals have written and signed to state what services they will provide, for example, the GP will monitor a service user’s ‘blood pressure’ every six months. The medication system used meets the health and safety needs of the service users. The Monitored Dosage System (MDS) has been improved. Protocols are in place for ‘as required’ (PRN.) The manager does a regular medication audit with records kept. The staff team have completed their accredited medication training. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23 The complaints and adult protection procedures available ensure that service users are protected from harm. EVIDENCE: There have been no complaints received at the home or the CSCI since the last inspection. The complaints procedure is also available in audiotape. The home makes use of Birmingham’s Multi-Agency Guidelines for the Protection of Vulnerable Adults. The staff spoken to were conversant with the guidelines. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 24 25 27 and 30 The home was clean, warm and fit for its purpose and generally provides service users with a safe, homely and comfortable environment EVIDENCE: The home was warm, clean and hygienic. It is decorated and furnished to meet the needs of service users. On the ground floor there is a comfortable lounge. The hallway and office have been recarpeted. The service users bedrooms were clean with a cosy atmosphere. They were decorated and furnished to the likes and wishes of service users. The bathroom on the ground floor is showing signs of wear and will need to be refurbished in the near future. The seal around the bath is no longer fit for its purpose and must be resealed to avoid water leaking down the walls and may cause damp and give offensive odours. The manager is aware of the situation. The bathroom on the first floor has been totally refurbished, the bath has been lowered and ‘grab rails’ fitted to assist service users using the bath. The walls and floor have been retiled. A new shower unit has been installed. During the refurbishment the window restrictor was not refitted to the window. This must be fitted immediately to protect service users from injury. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 15 There is a cupboard in the lounge that houses the fuse box and electric meter, the door is broken and must be replaced to protect the safety of service users. In the laundry there were two sharp screws protruding from the wall next to the sink unit. These must be removed to prevent injury to service users and others. The central light fitting appears to have tissue paper around it. This is a safety hazard and must be removed immediately. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 The homes recruitment procedure is robust and ensures service users are protected from harm. Staff have received training to enable them meet service users needs. EVIDENCE: Staffing records were inspected all the information and documentation required by Schedule 2 of the Regulations are on the individual files. It would be good practice to have staff information held in individual folders. The staff group have had induction training and have done all statutory training. Staff members are doing NVQ level 2 training two staff members have completed the training. The deputy manager has completed NVQ level 4 Staff meeting take place and a record kept. The staff group are having individual supervision sessions every two months. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home is well managed to promote the health and safety of service users. EVIDENCE: The manager has recently gained his NVQ Manager’s Award. The home is well run. The manager has developed systems to gain information from others on the services that the home is giving. The information is obtained from GPs, Pharmacists, Community Nurses, Dentist, families and visitors. Service users are assisted to ascertain their views. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 18 Comprehensive fire procedures are in place. Service contracts of electrical and gas appliances were available and in date. Staff are trained in First Aid, Moving and Handling, Fire, Health and Safety. Basic Food Hygiene and Infection control. The hot water temperatures are being tested, however, the taps tested must be identified and recorded accordingly. In the laundry there was two sharp screws protruding from the wall next to the sink unit. These must be removed to prevent injury to service users and others. The central light fitting appears to have tissue paper around it. This is a safety hazard and must be removed immediately. The cupboard in the lounge that houses the fuse box and electric meter, the door is broken and must be replaced to protect the safety of service users. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carlton Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. Standard YA24 YA42 YA 24 YA42 YA24 YA42 YA24 YA42 YA42 YA 30 Regulation 13.(4)(c) 13.(4)(c) 13.(4)(c) 13.(4)(c) 13.(4)(c) 23.(2)(b) Requirement The window restrictor must be refitted to the window of the first floor bathroom immediately. The paper tissues around the light fitting in the laundry must be removed immediately. The screws protruding from the wall next to the sink unit in the laundry must be removed. The door on the cupboard that houses the fuse box and electric meter must be repaired. The taps where hot water temperatures are tested must be identified and recorded. The seal around the bath on the ground floor must be replaced Timescale for action 15.06.05 15.06.05 16.06.05 25.06.05 16.06.05 22.06.05 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 YA27 Good Practice Recommendations The bathroom on the ground floor is showing signs of wear and tear and will need refurbishing in the near future. Carlton Road E54 S17085 Carlton Road V226648 110505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 1st Floor, Ladywood House 45-46 Stephenson Street Brimingham 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. 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