CARE HOME ADULTS 18-65
Charles House (Pb) 257 Birchfield Road Perry Barr Birmingham West Midlands B20 3DG Lead Inspector
Gerard Hammond Unannounced Inspection 27th October 2005 02:30 Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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 House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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 House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Charles House (Pb) Address 257 Birchfield Road Perry Barr Birmingham West Midlands B20 3DG 0121 331 4972 0121 331 4972 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) Alphonsus Homes Mr Edward Brown- Trainee Manager Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 21st April 2005 Brief Description of the Service: Charles House provides accommodation, personal care and support for up to ten people with learning disabilities. The Home is part of a group owned and run by a private company, Alphonsus Homes. The house is a large, wellmaintained, three-storey period style property situated in the Perry Barr area of Birmingham. It is set back from the main A34 route into the city centre. At the front of the house is a small, neat garden and limited off-road parking. To the rear of the property is an enclosed private garden with flowerbeds, lawn and patio areas, which can be accessed through the large conservatory or kitchen back door. A ramp and handrails have been fitted to facilitate access for people with sight or mobility difficulties. Each person living at Charles House has a single bedroom, and these are situated on all three floors of the Home. One bedroom on the ground floor has en-suite facilities. All other bedrooms have wash hand basins, and there are bathroom, shower and toilet facilities on all floors. There is no passenger lift facility in the Home, so most people living there must have good general mobility and be able to manage stairs. On the ground floor is a large lounge, which leads directly into the conservatory. There is also a full-sized dining room, giving access to the kitchen and also the office. The house is well served by public transport and close to a range of community facilities and amenities, including shops, pubs and restaurants, parks, places of worship and medical centres. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This visit was the second of the inspection year 2005-6. The report should be read in conjunction with the one written following the inspection carried out on 21 April 2005. Direct observation and sampling of records (including personal files, care plans and previous inspection reports) were used for the purposes of compiling this report. The Trainee Manager was interviewed formally and the Inspector met with six of the residents. Unfortunately, the communication support needs and degree of learning disability of the majority of people living in this house meant that it was not possible to seek their views directly. What the service does well: What has improved since the last inspection?
Clear efforts have been made to meet some of the requirements made at the time of the last inspection. Individual contracts have now been updated as required. Risk assessments have been cross-referenced with the care plans to which they relate. There have been continued improvements in the monitoring and recording of people’s activities, and this now also includes information about structured programmes delivered by the Organisation’s Day Service. The Adult Protection Policy has been reviewed and updated, and more staff have now completed training in the Protection of Vulnerable Adults From Abuse.
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 6 The garden fence has now been rendered safe, and the rainwater butt is now also secure. 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 House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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 House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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): 5 Residents now have individual contracts in writing that have been amended as required. EVIDENCE: There have been no new admissions since the last inspection. At that time, Standards 1, 2, and 4 were assessed and met in full. A requirement was also made that individual contracts (see Standard 5) should be developed to indicate the cost of the service provided, and to include the facility for signing or witnessing by a friend or relative, where individuals are unable to do this for themselves. The contract format has now been updated and amended as required. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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, 9 Care plans are being developed to include personal goals, and this work should be continued. Residents are supported to take risks, so as to enhance their opportunities for independence. EVIDENCE: Standards 6,7 and 9 were assessed at the last inspection: Standard 7 was judged to be met, and a requirement made that care plans and risk assessments should be further developed. It is clear that some thought has gone into considering ways of including individual goals in people’s care plans, and this work should now be built on. It is important that goals have outcomes that can be measured, so that they can be evaluated effectively. For example, the goal that “W to be exercising regularly with short walks” might be amended to show how often this might be (three times a week, every other day etc.) and suggest a desirable duration for the activity (ten minutes, half a mile). The manager advised that plans and risk assessments are currently under review, and this will be assessed at the
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 10 next inspection. It was noted that care plans and risk assessments are now cross-referenced, as required. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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 Residents are able to take part in appropriate activities and to access the local community. Work undertaken to assess the effectiveness of current activity opportunities should now be completed, and a follow-up action plan produced. EVIDENCE: Standards 15, 16 and 17 were assessed and met in full at the last inspection. A requirement was made that activity recording (see Standards 12 and 13) was in need of development so that a clear picture of the range and quality of opportunities enjoyed by individuals could be gained. The Manager was able to demonstrate that significant work has been done since the last inspection to collate data to inform this process, including input from day services. This information should now be analysed and an action plan produced, based on the findings of this exercise. It was noted that records now included social skills activities undertaken at home, and this is a positive addition to the “picture”. It is recommended that occasions when activities are offered but declined are also included. Completion of this work should provide some good material to support further goal setting and care plan development. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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): 19, 20 General practice ensures that residents’ healthcare needs are met appropriately, and that they are protected by policies and procedures for storage, handling and administration of medicines. EVIDENCE: Standard 18 was assessed and met in full at the time of the last inspection. A requirement was also made that the Manager should ensure that all residents had access to the services of a dentist on a regular basis. He advised that everyone living in the house was now registered with a local dental practice. There are some issues about two of the residents not tolerating dental treatment. This needs to be risk assessed and care plans adjusted to reflect this in both cases. The Medication Administration Record was examined, and seen to be complete. Protocols are in place in respect of PRN (“as required”) medication. The Manager reported that there had been some recent problems with incorrect doses of medication being sent down from the pharmacy. It is recommended that photocopies of prescriptions be retained at the Home so that any future prescribing errors can be appropriately challenged and rectified. It is further recommended, merely as a matter of good practice, that a photograph of each resident should be filed with his or her MAR sheets. It was noted that a recent
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 13 pharmacy audit report commented that Charles House is “a very well organised home”. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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): 23 General practice promotes the protection of residents from abuse, neglect and self-harm. EVIDENCE: Standard 22 was assessed and met in full at the last inspection. The Manager advised that nine members of staff have now received adult protection training. The adult protection policy was updated in May 2005, and now also includes local multi-agency guidelines as required. Action has also been taken with regard to the negative impact of one resident’s behaviour on the well being of other residents. A referral to the psychology service has been followed up and behaviour management strategies put in place. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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, 27, 28 While residents enjoy the benefits of living in a house that is generally comfortable and homely, there are a number of outstanding issues in need of attention. EVIDENCE: In addition to the Standards identified above, Standard 30 was also assessed at the last inspection, and this was met in full. Some of the requirements relating to environmental issues, made at the time of the last inspection, have been met. In the garden, the rainwater butt has been made secure, and the razor wire on the garden fence has been removed. New emergency light and automatic door closure fittings have been installed on the upper floor of the house. The window restrictor in the top floor w/c shower room has been repaired, but the flooring and the broken tile still need to be replaced. It is disappointing to see that the dining room carpet is still in need of cleaning or replacement, and that the new kitchen floor covering has yet to be installed. Maintenance work on the conservatory is also still outstanding. As indicated in the last inspection report, some of the bedroom furniture and floor coverings are now showing signs of their age. A copy of the Home’s maintenance and renewal programme should be submitted to CSCI, indicating clearly when these issues will be addressed.
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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): 31, 32, 33, 35 Some staff members need to have a copy of their job descriptions, so as to ensure that all are clear about their respective roles and responsibilities. The effectiveness of the staff team has been improved by increasing the numbers of staff regularly on duty on each shift, and by expanding the numbers of bank staff. A current training and development plan is required, so as to assess qualifications and training needs appropriately. EVIDENCE: At the last inspection Standards 35 and 36 were met in full. Sample checking of staff files found that not all records contain a job description. It is recommended that each member of staff’s personal file contain a signed copy of his or her job description. There is evidence that this matter is being dealt with, and this task should now be completed. The staffing position in the Home has been improved since the last visit, and there are now usually four people on duty on each shift. Also, the Manager reported that the size of the staff “bank” had increased, thus lessening the likelihood of having to employ agency staff, and supporting better continuity of care.
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 17 As reported previously, the Organisation offers a rolling programme of training, and there is evidence of staff attending courses since the last inspection. However, in order to assess accurately the qualifications and training needs of the care team, an up to date training and development plan is required. This should show, for each member of staff, qualifications gained and training completed (or currently undertaken) and highlight any gaps (including “refreshers”), indicating when outstanding training is scheduled, and who is to deliver it. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 18 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, 39, 41 The Home is generally well run, but action should now be taken to submit a completed application to register a Manager. Quality assurance measures need to be developed so as to represent the views of people using the service. Record keeping, policies and procedures are generally satisfactory, but outstanding requirements should now be addressed. EVIDENCE: A requirement was made at the time of the last inspection that an application should be submitted to register a Manager for the Home, and this remains outstanding. The current Trainee Manager is still supervised by one of the Organisation’s Service Managers, and is continuing to work towards attaining the Registered Manager’s Award. As reported previously, there are a number of quality assurance measures already in place within the Organisation, and these continue to be developed.
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 19 However, the requirement made at the time of the last inspection relating to this remains outstanding. Quality assurance systems should provide for direct feedback from those who use the service. Where this is difficult or not possible (e.g. because of individuals’ learning disabilities) then steps should be taken to include the views of others from outside the service that may be able to express views on behalf of the residents. This might be a relative, a friend or professionals involved in their care and support. This aspect should now be addressed, and the results of quality monitoring made available to interested parties. The Food Risk Assessment still requires updating: this is a minor adjustment needed to reflect actual practice, as this occurs specifically in the Home. Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 X 2 2 X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 2 3 X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Charles House (Pb) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X 3 X X DS0000016722.V262693.R01.S.doc Version 5.0 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. 1 Standard YA6 YA9 Regulation 15 13 (4) Requirement Further develop care plans and risk assessments in keeping with identified goals, and review as required. Reviews of care plans and risk assessments must show who takes part and how decisions are made. Further develop individuals’ activity recording, show how choices have been offered and made and indicate the purpose of activities. Analyse the data gathered, and use this information to inform future care planning. Produce action plan to indicate how this will be achieved. Clean or replace the dining room carpet. Replace the flooring in the top floor w/c shower room. Complete outstanding maintenance on conservatory. All outstanding since 21/04/05 Replace kitchen floor covering so as to complete refurbishment. Submit an up to date maintenance and renewal
Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 22 Timescale for action 31/01/06 2 YA12YA13 16 (2m-n) 31/01/06 3 YA24 YA27 YA28 23 (2) 31/01/06 4 YA32YA35 18 (1a-c) 5 YA37 8&9 6 YA39 24 (1-3) 7 YA41 17 8 YA42 13 (4c) schedule to CSCI, indicating when outstanding work will be completed. Forward an up to date staff training and development assessment and plan to CSCI, as indicated in the main body of this report. Complete an application to register a Manager for the Home. Outstanding since 21/04/05 Develop the Home’s Quality Assurance and Monitoring Systems to include feedback from interested parties. Collate this information, analyse it and make it available to those involved. Outstanding since 21/04/05 Review and update the Food Risk Assessment to reflect current practice within the Home. Outstanding since 21/04/05 Replace the broken tile by the wash hand basin in the upper floor w/c shower room. Outstanding since 21/04/05 31/01/06 31/12/05 31/01/06 31/12/05 31/12/05 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 YA20 Good Practice Recommendations Retain photocopies of prescriptions and check medication received into the Home against these. Keep a current photograph of each resident with his or her Medication Administration Record (MAR) Ensure that each member of staff has a signed copy of his or her job description maintained on individual personal files. 2 YA31 Charles House (Pb) DS0000016722.V262693.R01.S.doc Version 5.0 Page 23 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
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