Inspection on 22/05/06 for 56-58 Carlton Road

This inspection was carried out on 22nd May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

56-58 Carlton Road 19/12/05

56-58 Carlton Road 15/06/05

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) Small Heath Birmingham West Midlands B9 5EB Lead Inspector Sara Gibson Unannounced Inspection 22nd May 2006 09:00 Carlton Road (56-58) DS0000017085.V289088.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 Carlton Road (56-58) DS0000017085.V289088.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. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Carlton Road (56-58) Address Small Heath Birmingham West Midlands B9 5EB 0121 772 4078 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) ash786@btinternet.com Mr Arshad Mahmood Mr Arshad Mahmood Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Carlton Road (56-58) DS0000017085.V289088.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 19th December 2005 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 (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day by one Regulation Inspector, with the full assistance of both the Manager and the Deputy Manager. The home has three service users, two of which are long-term service users, and one service user who has been in the home for less then a month. A tour of the premises was undertaken, and records and documentation were examined including service users care plans, risk assessments, menu’s, staff personnel files and training records. Quality assurance questionnaires completed by advocates and family were also seen. What the service does well: What has improved since the last inspection? What they could do better: Care plans are good but the review dates must be adhered to, at present they are a couple of months out of date. Entries in the service users daily logbooks have improved but a statement about the service users emotional well being should be added. Receipt of medication needs to be logged and signed for on the Medication Administration Chart (MAR chart). Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 6 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 (56-58) DS0000017085.V289088.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 Carlton Road (56-58) DS0000017085.V289088.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, 3, 4, 5 The homes assessment process and information given to prospective service users and their representatives, give detailed guidance to enable service users to make an informed decision about choosing to live in the home. EVIDENCE: A full assessment is carried out prior to a service user entering the home; this takes place over a period of time and continues when the service user enters the home. The service users, family, friends and the multi-disciplinary team all participate in the assessment process. The home offers trial visits to prospective service users as part of the assessment process. Service users needs and aspirations are assessed, and this information then helps to form the service user care plan, giving staff the information they need to support the service users in their daily lives. Each service user has a contract of residency with the home. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9 The care plans are detailed, thorough and enable staff to support the service users and meet their individual needs. Strategies for managing risks are clearly identified. EVIDENCE: The care plans of two service users were examined. The third service user is new to the home and is still under assessment, so a care plan has not yet been formulated. The care plans seen contained detailed and precise information about the service users which enable staff to provide “person-centred care”. Service users are involved in care plan reviews, although their participation is somewhat limited due to their complex needs. However, these service users have lived at the home for a number of years and staff know them well and are aware of their needs and wishes. Advocates and family also participate in the care plan reviews. Risk assessments and living skills for service users are again detailed and thorough, although review dates must be adhered to. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 10 Daily logbooks record the service users activities during the day, these are now more detailed but should also include entries about the service users emotional well being. It is recommended that care plan files are tidied up, archiving old documentation, dividing each section to enable the current information for care plans, risk assessments, reviews and living skills to be accessed easily. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 11 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, 14, 15, 16, 17 Service users are supported, and given choice and control over their daily routines. Appropriate activities are offered, and family relationships are maintained. Service users dietary needs are well catered for with a balanced and varied diet on offer. EVIDENCE: The home has a detailed weekly plan of activities showing the activities taking place on a daily basis. These include trips out to local places of interest, leisure activities and meals out. Visitors to the home are made very welcome and encouraged to stay for meals. Service users are taken out regularly by their advocates and family members. Service users are encouraged to assist with household chores, such as bed making and washing up, on the day of inspection a service user was observed helping to Hoover the lounge. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 Service users are well supported with their personal needs by staff who know the service users very well. Service users health needs are met by the staff with the input of the multi-disciplinary team. Good records are kept on service users physical and emotional health needs. Medication administration is good. Staff are competent and administer medications safely. EVIDENCE: Staff support service users with their personal needs giving prompts and guidance allowing service users to retain their independence. Although, service users verbal communication skills are limited, staff have a good understanding of what service users require from observing facial expressions and body language. Service users looked well, and were well groomed. Input and advice from the multidisciplinary team, such as the GP, District Nurse and Community Psychiatric Nurse is sought when necessary and fully documented in the service users care plan. Medications are stored in a locked cabinet, and safely administered by staff following the homes medication policies and procedures. Receipt and returns of all medication are documented and verified by the local pharmacist that supplies the service users medications. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 13 The Manager must ensure that receipt of medications into the home is logged in and initialled on the Medication Administration Charts (MAR charts). MAR charts are complete and there are no missing signatures. The Manager carries out regular medication audits and all staff have completed accredited medication administration training. Carlton Road (56-58) DS0000017085.V289088.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): 22, 23 The Complaints and Adult Protection procedures followed by the home ensure that service users are protected from harm. EVIDENCE: No complaints have been received since the last inspection. The home has a complaints policy and procedure in place. The home follows the Birmingham Multi-Agency Guidelines for protection of vulnerable adults. All staff have undertaken training in Protection of Vulnerable Adults (POVA), and have a good understanding of the potential indicators of abuse. Carlton Road (56-58) DS0000017085.V289088.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): 24, 25, 26, 27, 28, 29, 30 The home is warm, clean and comfortable and provides a safe environment for the service users to live. EVIDENCE: A tour of the home was undertaken during the inspection. The home is warm, clean and comfortable. Service users bedrooms are spacious and personalised for each service user. The décor upstairs requires some attention, but the homes repairs and maintenance programme has planned for this later this year. The bathroom has been fully refurbished to a good standard and allows service users easier access to the bath. A new shower has also been installed. The bathroom, kitchen and utility areas were clean and hygienic. Ground floor communal areas have been redecorated, are warm, homely and provide comfortable living areas for the service users. Radiators in the home were very hot to the touch and uncovered. The home has carried out a risk assessment on the radiators and found they were not a hazard, but it would be advisable to have the radiators covered to prevent any scalds. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 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 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, 33, 34, 35, 36 Service users are supported b y a competent, qualified staff team who fully understand their roles and responsibilities. The home has a robust recruitment procedure in place, which protects the service users from harm. EVIDENCE: The home has robust recruitment policies and procedures in place, which protect the service users from harm. Two staff files were examined and were seen to contain all the required information including references and CRB checks. Staff are well trained and have the skills and competency to meet the service users needs. Training undertaken by staff includes Moving & Handling, Health & Safety, Protection of Vulnerable Adults, First Aid, Medication Administration, Food Hygiene and Challenging Behaviour. A number of staff hold or are working to an NVQ in Care. The Manager regularly researches new ideas and items of interest pertaining to the home and the service users, and cascades the information down to the staff team. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 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 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, 38, 39, 41, 42 The home is well managed and promotes the health, safety and welfare of service users. EVIDENCE: The home is run in the best interests of the service users. The Manager is extremely competent and supports his staff team very well. Formal supervision of each staff member takes place regularly, and any issues raised are followed through and actioned. The homes policies and procedures are regularly reviewed and updated to reflect the service provided, and to protect the service users rights and best interests. The Manager carries out regular Health & Safety audits and risk assessments on the home, and staff have received training on Health & Safety issues. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 18 Service user daily logbook entries have improved to show the activities undertaken by the service user, but there needs to be further input regarding the service users emotional well-being. The health, safety and welfare of service users is promoted and protected. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 4 3 3 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 3 26 3 27 3 28 3 29 N/A 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 4 4 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 N/A 4 4 3 3 2 3 X Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA41 Regulation 17 12(a) 13(2) 17 Requirement Entries into the service users daily logbooks must include a statement about the service users emotional well being. The amount of medication received into the home must be logged and signed for on the Medication Administration Chart (MAR chart). The Registered Person must ensure that care plan review dates are adhered to. Timescale for action 24/06/06 2. YA20 24/06/06 3. YA6 15(2) 24/06/06 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 Care plan files should be tidied up, old documentation archived and the current information organised into sections such as care plans, risk assessments, and reviews to enable up-to-date information to be accessed easily. The upstairs decor is showing signs of wear and tear, and should be redecorated shortly, see Standard 24.12. The radiators in the home are very hot to the touch, and DS0000017085.V289088.R01.S.doc Version 5.1 Page 21 2. 3. YA24 YA24 Carlton Road (56-58) 4. 5. 6. YA34 YA36 YA20 although they have been risk assessed it is recommended that radiator covers should be in place to prevent any scalds occurring. The application form needs further development to ensure that full information can be detailed by a prospective employee. The supervision form needs further development to include the headings listed under Standard 36.4. Medication audits can be carried out and advice sought from the local pharmacist, see Standard 20.12. Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 22 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 Carlton Road (56-58) DS0000017085.V289088.R01.S.doc Version 5.1 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!