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Inspection on 09/01/06 for Charles Davies House

Also see our care home review for Charles Davies House for more information

This inspection was carried out on 9th January 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service was working well with the residents, at a pace appropriate to each of them, towards the goal of preparation for independence or supported living situations. The home continued to provide a good standard of accommodation for the residents with appropriate furniture and furnishings. The planning of care was good with residents being involved in the writing of their essential lifestyle plans and in recording of daily records. The move to the home and into independent living from the home was well managed with regular visits over a period of time. There was good multi-agency working to meet the health and emotional needs of the residents. Residents were supported to fulfil their potential by securing suitable activities during the day and maintaining contact with relatives and friends wherever possible.

What has improved since the last inspection?

The care planning process had improved with evaluations being carried out on a regular basis and with timescales included for meeting the resident`s goals and aspirations. There was improved recording of the pre-admission visits to the home by prospective residents.

What the care home could do better:

Staff needed to undertake fire training and the evaluations of the care plans needed to identify why goals had not been achieved and the actions to be taken to assist in achieving them.

CARE HOME ADULTS 18-65 Charles Davies Hse (Hock) 388 Lodge Road Hockley Birmingham B18 5PW Lead Inspector Kulwant Ghuman Unannounced Inspection 9th January 2006 10:15 Charles Davies Hse (Hock) DS0000016862.V277244.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 Charles Davies Hse (Hock) DS0000016862.V277244.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. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Charles Davies Hse (Hock) Address 388 Lodge Road Hockley Birmingham B18 5PW 0121 523 8880 0121 551 5194 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) Mind in Birmingham Mr Martin McKinley Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 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 within a 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 bed-sits, 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 Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection over part of the day on 9th January 2006. This was the second statutory visit for 2005/2006. In order to get a full overview of the home this report should be read in conjunction with the report of July 2005. As part of this inspection the manager was spoken with, some care documents and health and safety documents were sampled and two of the 12 residents were spoken with. The accommodation of one of the residents was inspected. What the service does well: What has improved since the last inspection? What they could do better: Staff needed to undertake fire training and the evaluations of the care plans needed to identify why goals had not been achieved and the actions to be taken to assist in achieving them. Charles Davies Hse (Hock) DS0000016862.V277244.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. Charles Davies Hse (Hock) DS0000016862.V277244.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 Charles Davies Hse (Hock) DS0000016862.V277244.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 There was written information available for prospective residents and families to assist them in deciding whether the home was suitable for them. Residents were assessed before admission and extensive introductions to the home undertaken in order to determine that the needs of the residents could be met. EVIDENCE: There was a statement of purpose and service user guide available in the home. The file of one resident who was soon to move into the home was sampled. It evidenced that information had been gathered regarding the individual’s needs from other agencies. An assessment had been carried out of the needs of the resident and this involved input from him as well as the assistance identified by the staff. A care plan and risk assessments would be set up once admission to the home had been agreed. The file further evidenced a number of visits to the home by the resident over several months to familiarise himself with the home and the other residents. There had been an extended introduction to the home due to ongoing medical interventions. The file had been prepared for admission with relevant paperwork in place to be completed on admission. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 9 The file of another resident was sampled which also evidenced that the needs of the resident were being assessed, care plans (ELP’s) written up and regularly reviewed and that risk assessments were in place. There were licence agreements in place. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 The needs of the residents were being assessed and a plan up drawn with the involvement from the resident. The residents were consulted about the life they led and how their goals were to be achieved. EVIDENCE: In conjunction with the residents the home prepared an Essential Lifestyle Plan (ELP) that identified the resident’s needs and aspirations. A large amount of information was collected in order to assess the needs and aspirations of the residents. Personal goals were identified. The ELP’s were reviewed on a monthly basis in an effort to identify whether objectives were being met. The ELP’s could be further improved to show that where objectives had not been achieved the reasons why and what actions were being taken to assist their achievement. One of the residents told the inspector that they were aware of the information held about them and that they could have access to the records. There was evidence that the residents were encouraged to make recordings about their care at the home. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 11 Residents were encouraged to take responsibility for their lives by identifying and arranging courses, organising medical appointments, and undertaking shopping and cooking a number of meals for themselves whilst other meals could be provided by the cook. The residents were responsible for their laundry and for keeping their own accommodation clean. Some of the residents were able to travel independently where as others required some assistance from the home to arrange transport. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Residents were enabled and encouraged to lead 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: There was ample evidence in the home that residents followed an individualised lifestyle and opportunities for personal development were encouraged. Most of the residents attended day centres, courses to develop their independence skills and employment preparation schemes. One resident had secured some employment following one of the employment preparation schemes and was looking to move into independent accommodation. Residents were encouraged to travel independently where possible following travel training and transport was organised where this was not possible. Residents went shopping, used local health facilities and visited family and friends in the community. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 13 There was evidence of friendly and supportive relationships between the residents and staff. Some residents visited their families and close friends in the local community with some staying overnight. Leisure activities were encouraged where identified by the residents. One of the residents told the inspector that they had been out during the summer on some trips but could not remember where. There were no rigid rules in the home but residents were encouraged to wake at times that would fit in with their respective daily routines. Residents had keys to their bedrooms and the inspector was told by one of the residents that the staff would wait to be asked to come in. The resident stated that he had no complaints about the food provided by the cook who knew his likes and dislikes. As part of the resident’s individual plan he prepared lunch twice a week with assistance from a member of staff. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 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 Davies House were independent and did not require specific assistance with personal care apart from some prompting. There was good evidence that the health care needs of the residents were being met. There were regular reviews with consultants, CPNs and GPs. Residents were encouraged to make their own appointments as observed during the inspection and residents asked the staff for their medication at the time they were due to take it to encourage responsibility for the management of medication whilst ensuring it was being taken. Residents could then move to the next stages of taking more responsibility for managing their own medicines as part of a controlled programme. There was evidence that residents were supported emotionally when they were having difficulties with families or friends were unwell. There was also evidence that the residents were seeing the dentist when required. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 15 The medication systems were not assessed during this inspection as there were good systems in place and the recommendation to ensure that a copy of the most recent prescription was kept with the MAR charts had been attended to. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Residents were safeguarded by the policies and procedures in the home. EVIDENCE: One of the residents told the inspector that they could raise issues with any of the staff and the issues would be looked into. There were good professional but friendly interactions observed between staff and residents with an air of openness conducive to alerting the staff of any issues. There was a suitable complaints procedure in place. There had been no complaints made to the CSCI or the home directly about the service. There were forms available to record any issues raised formally or informally. There was an adult protection procedure in place and a copy of the multiagency guidelines were available. There was an updated version of these guidelines available now and the home was advised to access the new ones. The organisational procedures were acceptable but it needed to clarify the amount of information gathering to be done at the home before referring a suspicion of abuse to the social worker. During discussion with the manager this was not clear. The adult protection procedures were due to be reviewed by the organisation in the near future. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 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 the following standard(s): 24, 25, 26, 28, 30 The home was well maintained, clean and met the needs of the resident seen. EVIDENCE: During this inspection the inspector visited one of the residents in his apartment and saw the communal areas of the unit housing the office. There had been no changes to the accommodation since the last inspection. The apartment seen by the inspector met the needs of the resident who had personalised the area with personal belongings. The accommodation consisted of sleeping and sitting area, an en-suite bath and toilet and a kitchen including washing machine/tumble dryer, cooker and general kitchen furniture. The apartment contained the appropriate furniture including table and two chairs. The furniture in the sitting room in the other unit contained furniture of a good standard that was homely and comfortable. All areas of the home seen were clean. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 18 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): 34 Recruitment procedures were good and safeguarded the residents. EVIDENCE: No new staff had been appointed but the records for staff were kept on site with evidence of identity, completed application forms and references in place. The CRBs were held at the head office and a letter from them showing confirmation that CRB clearance had been received was requested. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40, 41, 42 The home was well managed and the health and safety of residents and staff was well managed. EVIDENCE: The home was well managed and the resident’s needs met ensuring that they led individual and fulfilling lives was of paramount importance. There were policies and procedures in the home to safeguard the resident’s rights and best interests. Record keeping in the home was good and in line with the policies and procedures. Fire records were sampled and found to be up to date apart from the 6 monthly fire training for staff. Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X X 3 3 3 X Charles Davies Hse (Hock) DS0000016862.V277244.R01.S.doc Version 5.1 Page 21 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. 4. Standard YA3 Regulation 14(1) Requirement 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. (Partly met at this inspection.) The adult protection procedures must be reviewed to make clear the actions to be taken in the event of an allegation or incident of abuse. The storage heater identified as needing to be guarded must be guarded when appropriate. Staff must be provided with fire training. Timescale for action 01/04/06 2. YA23 13(6) 01/04/06 3. 4. YA42 YA42 13(4)(c) 23(4)(d) 01/04/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charles Davies Hse (Hock) DS0000016862.V277244.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 Charles Davies Hse (Hock) DS0000016862.V277244.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!