Inspection on 05/07/05 for Charles Davies House

This inspection was carried out on 5th July 2005.

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

Other inspections for this house

Charles Davies House 07/10/08

Charles Davies House 13/12/06

Charles Davies House 09/01/06

Charles Davies House 17/02/05

Charles Davies House 25/05/04

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

CARE HOME ADULTS 18-65 Charles Davies House 15 Park Road South Hockley Birmingham B18 5QL Lead Inspector Kulwant Ghuman Unannounced 5th July 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. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Charles Davies House Address 15 Park Road South, Hockley , Birmingham B18 5QL 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) 0121 523 8880 0121 523 8880 Mind in Birmingham Cheryl Yardley (Not registered) Care Home 13 Category(ies) of Mental Disorder - Mental Disorder - (13) registration, with number of places Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 2005 Brief Description of the Service: Charles Davis house consists of three units that can accommodate up to 13 younger adults with enduring mental health issues. Focus Housing Association owns the building and MIND in Birmingham provides the care and support. The home is located withina residential area of Birminghams inner city, approximately two miles from the city centre. The home is close to shops, bus services, a post office and a medical centre. Two of the houses provide single rooms and a communal lounge and dining area for up to nine people. The other unit consists of four bedsits, including a kitchenette and bathroom. The aim of Charles Davis House is to provide support and training to the residents in order that they can progress onto either independent living or supported living. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over part of a day in July 2005. This was the first of the two inspections of the 2005/2006 programme. This was the first inspection of the home since the closure of the core unit resulting in a reduction in the number of people accommodated from 31 to 13. The core unit building has been vacated with all the residents having been found alternative placements. The buildings have been boarded up and it is hoped that Focus Housing Association will decide the future of the building in a short period of time as the fencing has already been broken in several areas and may begin to attract unwelcome attention. During the inspection the inspector was able to talk to three staff, the manager and four of the residents. A tour of two of the units was carried out with the assistance of two of the residents. The unit housing the bedsit accommodation was not toured during this visit. Three resident files were sampled along with one staff file and some health and safety documents. What the service does well: Charles Davis House has managed a very difficult time with a great deal of understanding whilst the core unit was closed down. By liaising with other professionals such as social workers and CPN’s and working with the residents suitable alternative placements have been found for them. One member of staff was given the role of maintaining contact with the residents who moved elsewhere to ensure that they settled in. The residents who moved to other placements continue to maintain contact with the home and the residents remaining at Charles Davis House. Charles Davis House continues to provide a good standard of accommodation for the residents with appropriate furniture and furnishings. The residents are encouraged to live an independent life as far as possible but staff continue to ensure that their medical needs are met. The home provides for a variety of ways in which the resident are able to manage their meals ranging from total independence where the resident is provided with money so that they undertake their own shopping or for their meals to be prepared for them by the chef. The home encourages the residents to be involved in the writing up notes in their own files and this process is ongoing. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 6 There is a stable team of staff at the home. What has improved since the last inspection? 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. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 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 Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 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) 1,2,3,4,5 There was no information available for the residents so that prospective residents did not have the information required to make informed decisions. Residents needed to be given terms and conditions of residence so that they know what services they can expect to receive. EVIDENCE: The manager was currently working on the development of the statement of purpose and service user guide. One of the three service user files sampled did not include evidence that an assessment had been carried out prior to the resident moving to the home. The manager stated that the care plan from the social worker had not yet been received but that the home had carried out its own assessment however this was not documented. There was no evidence that a pre-admission visit to the home had been undertaken by the resident. Charles Davis House used the Essential Lifestyle Plans and these were written up with the involvement of the residents. One of the files sampled did not have a completed ELP but did contain some information regarding how the staff were going to achieve the short term and long term goals identified. The other files did not have the short term and long term goals identified. These plans needed to be improved so that there was clarity for all concerned regarding the goals to be achieved and what actions would be needed to achieve this and how the individuals would be assisted to achieve the goals. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 9 There was a tenure agreement in place for two of the residents but not the third. The manager stated that there would be new tenure agreements needed. The needs of the residents seen appeared to be met in a flexible manner. There were good interactions between staff and residents. The residents spoken with were happy with the services being provided at Charles Davis House. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 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 standard(s) 6,7,8,9,10 Essential Lifestyle Plans showed that the residents had been involved in identifying their needs and how they would be met. Residents were enabled to live independent lives and take control of any risks as far as they were able to enable them to have control over their lives. EVIDENCE: The residents were helped to write the ELP’s themselves and included what they felt was important. The ELP’s needed to be clear in the way that the staff would assist and encourage the residents to achieve their stated goals. There needed to be some timescales to be used as a guide for when the goals should be achieved however, these needed to be flexible depending on the rate at which the residents developed their skills. One of the files showed that many of the agreements, for example, wishes following death, staff entering bedrooms and property inventory had not been completed. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 11 The ELP’s were being reviewed on a monthly basis. It was pleasing to note that where possible the residents were able to undertake their own reviews. Where staff were undertaking the reviews they needed to ensure that where an issue was being carried over from one month to the next this was identified and steps taken to either achieve the issue or discuss with the resident why it wasn’t being achieved. There were no rules and regulations that limited the lives of the residents. Residents enjoyed individual lifestyles with some undertaking training for independence, some attending day centres, some visiting families and others deciding to stay in their bedrooms for most of the days. Some of the residents helped in keeping the home tidy and undertook chores such as laundry and cooking. The records were stored in compliance with data protection guidelines. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16,17 Residents were enabled and encouraged to leave independent lives that were organised to meet their needs. Residents were able to meet with friends and relatives on a regular basis and prepared meals were available if they did not wish to prepare their own meals. EVIDENCE: The inspector was able to speak with four residents. All confirmed that they were able to lead a flexible life with limitations only being put in place where health and safety was an issue. The residents undertook different activities according to their wishes and needs. The residents remained part of the local community through development of their own friendships and continued contact with residents who had left the home. One of the residents had a job in the locality. Residents spoke with the inspector about their skills regarding the use of the local bus service. The residents confirmed that they were happy with how they Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 13 spent their leisure time. Although there were three units in the home there was a lot of interactions between the units in the communal areas where they watched the television or chatted with each other and the staff. Residents told the inspector that there were trips on offer that they could go on, that they could have visitors to the home and also went out to stay with friends as well. Charles Davis House provided some residents with all their meals although the majority had the evening meal cooked by the chef but the other meals were prepared by the residents themselves although the food was made available by the home. The chef also worked as a trainer assisting the residents develop their cooking skills. There were some residents who were totally independent and bought their own food and cooked all their meals. The residents were very happy with the meals provided and confirmed that there was always an alternative available or an alternative would be prepared if they didn’t like what had been prepared. They were also introduced to new dishes. Recently the home had had a tandoori meal and were due to have a Cantonese meal within the following week. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The personal and health care needs of the residents were being met and residents were enabled and encouraged to take responsibility for these areas of their lives. EVIDENCE: The residents at Charles Davis House are independent and do not require specific assistance with personal care. There was evidence in the files that the health care needs of the residents were adequately met. The residents were prompted to have their medicines and attend doctor and hospital appointments. Residents were encouraged to take responsibility for seeking their own medical treatments for example, one resident who sometimes self harmed was encouraged to access the emergency services if needed. One of the residents was assisted to make an appointment to see the doctor on the day of the inspection. The staff managed the medicines for some residents completely whilst others were in various stages of independently managing their medicines. Some residents would come to the office for their medicines and would complete the MAR charts themselves, others would take a weekly supply and keep it in their room and compliance checks were carried out on a random basis. There were Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 15 good systems in place for the management of medicines. Medicines were acknowledge and recorded on receipt into the home. A recommendation was made that a copy of the most recent prescription was kept with the MAR charts. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 16 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) These standards were not inspected during this inspection. EVIDENCE: Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 17 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) 24,25,26,27,28,29,30 The home is well maintained and provides comfortable accommodation for the residents including bedrooms, that afford privacy, and communal areas that allow mixing between the three units. One unit allows residents to have near total independence in preparation for independent living. EVIDENCE: The inspector was shown around two of the units by two of the residents. These areas were seen to be appropriately maintained. The two bedrooms seen by the inspector met the needs of the residents. There were televisions and hi-fis in the bedrooms as required by the residents. One of the bedrooms was quite cluttered but the resident was quite aware that this needed to be reduced. Residents had keys to their bedrooms and to enter the units from outside. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 18 The bathing and toilet facilities appeared to meet the needs of the service users in the units. There was a choice of bath or shower available. Residents needed to be encouraged to return bars of soap to their rooms after use from the bathing facilities to minimise the risks of cross infections. There were appropriate dining and sitting areas in the units. Furniture and fittings were appropriate. The unit comprising of bed sit accommodation was not inspected during this inspection. One of the residents needs had increased and an assessment had been undertaken by the occupational therapist for the provision of aids and adaptations. At the time of the inspection the home was found to be clean and hygienic. There were staff employed to carry out domestic duties. At the previous inspection the laundry in unit 2 required a wash hand basing fitting. This was not assessed at this inspection but the inspector was informed that the home intended to have washing machines fitted into each of the bed sits. The laundry facilities in the other two units were acceptable. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 19 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) 31,32,33,34,35,36 The residents were supported by a staff team that were aware of their needs and their long term goals. Recruitment procedures safeguarded the residents by ensuring that suitable individuals were appointed. EVIDENCE: Discussions with the staff showed that they were clear what their roles and responsibilities were. Staff were aware that the ethos of the home had changed somewhat to more of a rehabilitation role and they encouraged the residents to take more control of their lives. There was a training matrix in place but this was being updated, as there had been a lot of changes in the staff group. There were two staff on duty at all times during the day in addition to the manager. There was a domestic assistant that was shared with another home who cared for the communal areas. The care staff undertook these roles when the domestic assistant was not available. Residents were responsible for cleaning their own room although staff assisted and encouraged them. There Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 20 were care officers, one care assistant and a cook trainer at the home. There was one sleeping in member of staff on duty during the night. The staff file of the most recent addition to the staff team was brought from the head office for the inspector to sample but it was agreed that copies of the recruitment records would be kept at that the home. The supervision records of two staff were sampled and it was seen that the home was well on the way to achieving a minimum of 6 sessions a year. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 21 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) 37,38,39,42 The home is well managed and the health and safety of residents and staff was well managed. EVIDENCE: The manager had been in post since the 1st June 2005. She had undertaken the NVQ 4 in management and the registered managers award and had begun the NVQ 4 in care. The manager was knowledgeable about the needs of the residents and the running of the home. The manager needed to forward an application to be registered as the care manager to the CSCI. There appeared to be an open and comfortable atmosphere in the home with residents and staff able to access the office at all times. The policies and procedures in the home were not sampled during this inspection. The care plans, servicing and medication records were found to be well organised. The premises risk assessments were not inspected during this inspection and therefore those requirements made at the previous inspection have been brought forward. Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 22 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 1 3 1 1 1 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Charles Davies House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 3 x Version 1.40 Page 23 E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc 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. Standard YA1 Regulation 4(1) Requirement The registered person must ensure that the statement of purpose and service user guide are in place and contain all the required information. Copies to be forwarded to the CSCI and a copy given to all residents. A copy of the assessment and care plan for residents prepared by the placing authority must be obtained before a resident moves into the home. Pre-visits and any assessments carried out must be recorded. Individual plans must be put in place indicating how the goals identified were going to be achieved, with timescales and identifying how the residents would be supported to achieve their goals. The registered person must ensure that all residents are given a copy of the statement of terms and conditions of residence. The registered person must ensure that each resident has an individual care plan that identifies all the needs of the resident and how these needs Timescale for action 15.8.05 2. YA2 14(1) 1.8.05 3. 4. YA3 YA3 14(1) 14(1) 15.8.05 1.11.05 5. YA5 5(1)(b) & (c) 1.9.05 6. YA6 15(1) 1.11.05 Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 24 7. YA6 15(2)(b) 8. YA30 16(2)(j) 9. 10. YA30 YA34 13(3) 19 Sch2 11. YA42 13(4)(c) 12. YA42 13(4)(c) are to be met by staff. (Previous timescale of 1.9.04 not met) Actions must be taken when issues are identified as not having been met from one month to the next. Hand washing facilities must be provided in the laundry in unit 2. (Previous timescale of 31.12.04 not met) Bars of soap must be returned to residents bedrooms. Information regarding the recruitment procedure must be kept available in the home for inspection. The economy 7 storage heaters must be risk assessed and guarded where required. (Previous timescale given 7.3.05. Compliance not checked at this inspection.) The premises risk assessment needed reviewing in some sections and the fire risk assessment needed to be upgraded to the new assessment type introduced by West Midlands Fire Service and must be dated and reviewed on a regular basis. (Previous timescale given 1.4.05. Compliance not checked at this visit.) 1.11.05 1.9.05 1.8.05 1.9.05 1.9.05 1.9.05 13. 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 YA20 Good Practice Recommendations The most recent prescription should be kept with the current MAR charts so that the medicines can be checked. Version 1.40 E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Page 25 Charles Davies House Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local 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 Charles Davies House E54_S16862_CharlesDavisHouse_V237889_050705stage 4.doc Version 1.40 Page 27 - 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. 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