Inspection on 03/11/06 for Charles House

This inspection was carried out on 3rd November 2006.

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

Other inspections for this house

Charles House 29/07/09

Charles House 14/08/08

Charles House 04/09/07

Charles House 27/10/05

Charles House 21/04/05

Charles House 18/11/04

Charles House 21/04/04

Similar services:

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

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

CARE HOME ADULTS 18-65 Charles House (Pb) 257 Birchfield Road Perry Barr Birmingham West Midlands B20 3DG Lead Inspector Gerard Hammond Unannounced Inspection 3rd November 2006 09:05 Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 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.V313927.R01.S.doc Version 5.2 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.V313927.R01.S.doc Version 5.2 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 Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 27th October 2005 Brief Description of the Service: Charles House provides accommodation, personal care and support for 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, well-maintained, 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 and 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 and 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 either bathroom or 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 conservatory. There is also a full-sized dining room, giving access to the kitchen and also to 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. The current range of fees is said to be £800 - £1100 per week. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered from a range of sources prior to the visit being made to this service. These included previous inspection reports, service history and the pre-inspection questionnaire and incident reports completed by the Manager, and reports submitted on behalf of the Registered Provider. Direct observation and sampling of records (including personal files, care plans, safety records and other documents) were also used for the purposes of compiling this report. The Inspector was able to see all of the residents during the course of the visit: unfortunately, the degree of learning disability and communication support needs of the majority of people living in the house meant that it was not generally possible to seek their views directly. The Manager was formally interviewed and the Inspector was able to meet with other members of staff. A tour of the building was also completed. What the service does well: What has improved since the last inspection? A new system has been put in place to encourage key workers to review and evaluate people’s care plans on a monthly basis. Health action plans have now been introduced so as to promote individuals’ health and well-being. Work to upgrade residents’ bedrooms by redecorating and providing new furniture has continued since the last inspection. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 6 Staff are doing Learning Disability Awards Framework (LDAF) training, with a view to supplementing work towards improving the number of people currently qualified to NVQ level 2. The Manager has made some progress towards achieving the Registered Manager’s Award, and is working towards obtaining the A1 Assessor’s Award. This should also make a positive contribution towards helping staff members gain NVQ qualifications and improve the expertise of the care team. Senior care staff are now involved in providing formal supervision for other staff members. What they could do better: Service users’ contracts need to be updated so that information is current. Work already done to develop individuals’ goals should be continued and built upon. Staff need to be supported to use new tools for reviewing and evaluating care plans more effectively. It is recommended that the development of person-centred approaches be encouraged to supplement this further. Previous improvements in the quality of activity recording need to be taken up again. Individual activities should be clearly linked to people’s assessed needs and agreed goals. Recording should demonstrate the purpose of chosen activities and show how decisions have been made. Goals need to be evaluated and reviewed appropriately. Newly introduced Health Action Plans should be developed beyond the assessment stage and actively used to promote individuals’ well-being. One or two issues relating to medication require attention so as to ensure residents’ safety. All PRN (“as required”) medication should be supported with a protocol giving clear guidance about the circumstances in which medicine should be given. Creams and lotions should be labelled with the date of opening. A number of improvements are still required to the fabric and maintenance of the property, and these are detailed in the requirements section at the end of this report. Some of these have now been outstanding for more than eighteen months. Early attention should be given to the training and development needs of the staff team. Significant input is required to bring the complement of staff qualified to NVQ level 2 or above up to the required standard. The Manager should complete an application to be registered with CSCI without further delay. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 7 The annual report of quality assurance and monitoring activity of the service should now be produced. 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.V313927.R01.S.doc Version 5.2 Page 8 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.V313927.R01.S.doc Version 5.2 Page 9 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): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People’s needs are assessed as required, so as to inform care planning appropriately. Residents have individual contracts, but these need to be amended so that information is up to date. EVIDENCE: There have been no new admissions since the time of the last inspection. The personal files of three service users were sample checked and assessments were in place as required. It was noted that reviews of needs assessments had been carried out by social workers in April 2006. It was further noted that written contracts were in place on individuals’ files, but that these are now in need of updating to include the current scale of charges for each person. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 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, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans are improving, but are still in need of development so that they adequately reflect residents’ goals. Staff try and support residents to make decisions and choices, but recording needs to improve to demonstrate more clearly the extent of their involvement. Responsible risk taking is encouraged and seen as providing opportunities for learning and personal growth. EVIDENCE: Residents’ care plans are presented in a user-friendly summary format, and are appropriately indexed to make it easier to find important information. A system for key workers to monitor care plans each month has been introduced, and this initiative should be commended. However, it was noted that (on sampled files) these had not been completed every month, and the section for staff to complete action plans contained very limited entries. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 11 It was also noted that, though some progress has been made in terms of setting goals in people’s care plans, that these were also fairly limited. One person’s plan showed that she should have 1:1 sensory sessions each day, but the records showed that this had been achieved only nine times in a two-month period. There was also a reference to guidance from a Speech and Language Therapist, but no indication as to where this could be found. There is little evidence of the use of person-centred approaches. During the course of the visit, it was possible to observe directly members of staff supporting residents to make choices about what they wanted to do and where they wanted to go. This is frequently very limited because of people’s communication support needs and learning disabilities. Risk assessments are in place, with clear links to existing plans of care. These were not assessed in depth on this occasion. Conversations with the Manager indicate that responsible risk taking is viewed positively, providing opportunities for individual learning and personal development. Since the last inspection, some efforts have been made to encourage the development of appropriate goal setting, and the monthly key worker monitoring of care plans mentioned above is a good example of this. However, it may be that the staff team would benefit from some additional support to ensure that they have a good understanding of how to set goals and keep them under review. It is important that people know how to use properly the tools that have been given them, so as to ensure their effectiveness. Goals and action plans need to be specific, and the outcomes clearly measurable. Recording needs to show clearly how residents have been involved in making choices. This is an area of work that remains in need of further development. It is recommended that goals be set for each area of assessed need. It might be useful to set each member of staff a target to have identified a set number of goals for each of the individuals they support within a given period of time. Clearly, staff need support to achieve this effectively, and these issues should be raised as an identified training and development need. The development of the care team’s capacity to understand and use person-centred approaches would enhance this appreciably. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are able to take part in appropriate activities and to access their local community. However, record keeping in relation to individuals’ activity opportunities needs to improve in order to provide accurate information about their quality of life and support future care planning. People are appropriately supported to maintain contact with their friends and families, in accordance with their wishes. Staff encourage residents to be as independent as they are able, and respect their rights. Residents enjoy their meals and have access to a diet that is balanced, varied and nutritious. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 13 EVIDENCE: Sample checking of residents’ files showed that people attend local colleges and centres for structured activities during the day, and are able to access the local community with support. The organisation provides day activities from a local centre. Most people’s programmes involve a mixture of these components in varying degrees. Staff can support residents to access the community on days when they have no college or scheduled day centre activities. Records show that people use local shops, go to the pub for meals and drinks, go bowling and to the cinema and go for walks. In house activities include doing jobs around the house such as cleaning, helping in the kitchen, washing up, setting tables and hoovering. Other activities included using the “Playstation” computer games and going for takeaway meals. Records also show that residents are well supported to keep in touch with families, friends and loved ones. Some stay with families for weekend visits and also receive visits at the home itself, or are supported to meet up out in the community, according to individual preferences. Members of staff were directly observed encouraging residents to take an active part in jobs around the house, so as to develop their personal independence. One resident was seen being supported to vacuum clean the dining room and another helping to set the table and then later to clear away after the evening meal. Staff also respected individuals’ rights to decline activities offered, in an appropriate manner. Food stocks and records of meals actually taken were examined. Supplies were adequate and included fresh produce. Records provided further evidence that residents have access to a diet that is sufficiently varied and balanced, and appropriately nutritious. Residents were observed taking their evening meal together. Most sit at the large table in the main dining room. It is hoped that this will soon be replaced with new furniture (smaller tables) to reinforce a more homely atmosphere at mealtimes and make it easier for staff to give support to those who need it more appropriately. It is disappointing to note that such limited progress has been made since the last inspection with regard to improving the quality of the recording of residents’ activities. As things stand, it is difficult to assess accurately the quality and range of people’s activity opportunities. These are a prime indicator of the quality of life that individuals enjoy. There should be clear links between each person’s individual goals and the activity opportunities made available to them. At the moment it is not possible to establish these links on the basis of available evidence. It is true (as indicated above) that people do engage in structured activities, but it is not possible to see how these activities have been chosen and what involvement each person has had in making decisions about these, or how these are linked to their individual care plans. Set activities should be purposeful, and this should be clear from individual Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 14 plans. As indicated earlier, the development of person-centred approaches in individual care planning could support this significantly. The new tools being introduced to encourage key workers to monitor and review care plans each month should provide additional opportunities to feed information into the care planning system, if these are used appropriately. Again this may beg the question about how staff have been supported to ensure that these can be used most effectively. As a significant amount of people’s activities are actually delivered by the organisation’s day care “arm”, it should not be difficult to obtain appropriate information about what people have actually been doing during the day, and how choices have been made. In summary, each individual’s activity record should demonstrate clear links to his or her assessed needs and agreed goals and make clear the purpose of activities chosen (e.g. to develop or maintain skills, for therapeutic or health reasons, just for fun, etc.). It should be clear how activities have been chosen and provide sufficient information to make judgements about their suitability and / or future desirability. Staff need to understand why it is important to record relevant information, so as to present as full a picture as possible about the opportunities people enjoy. Failing to do so may give a false impression about each person’s true quality of life. By the same token, maintaining a full and accurate record of individuals’ activity opportunities should provide invaluable information to assist in future planning and service user satisfaction. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ personal care needs are met according to their identified needs by staff that treat them with warmth and respect. They are assisted to access primary and specialist healthcare support, so as to ensure that their health needs are appropriately met. General practice with regard to the storage, handling and administration of medication is satisfactory, but one or two issues require improvement so as to ensure residents’ welfare. EVIDENCE: General observations of residents’ dress and personal grooming provided evidence that people enjoy a good standard of basic personal care. Interactions between members of staff and residents were seen to be informal and relaxed, and support was given respectfully and in a warm and friendly manner. Individuals’ records provided further evidence that people are assisted to access primary and specialist health care support in accordance with their identified needs. There is continuing involvement from members of the Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 16 multidisciplinary team including GP, consultant psychiatrist, community nurse, psychologist, social worker, optician, dentist and chiropodist. Records include charts for monitoring individuals’ weights and also epileptic seizures, where appropriate. It was noted that one person’s record indicated that the Community Nurse was reviewing her epilepsy protocol. It is recommended that the reader be directed to where this is held on the file. A new format for Health Action Planning has been introduced, but this is still in the early stages of development. One person had a care plan goal “to lose weight by healthy eating”, but it was noted that, as yet, this was not linked to his Health Action Plan. Nor were there links to his activity plan, for instance to support this goal by creating opportunities for an increase in exercise. It is important that Health Action Plans are used pro-actively, and are not just another form of assessment used to identify issues, without following these through with appropriate action. The Medication Administration Record (MAR) was examined and had been completed appropriately. The record is generally supported with protocols for PRN (“as required”) medication, though it was noted that one person did not have one for prescribed Dioralyte (2 others were in place). Administration practice is supported by photographs of service users and “read and sign” sheets for staff. The medication store was in generally good order, but it was noted that three tubes of cream (all in date) had not been labelled with the date of opening. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ communication support needs and learning disabilities make it difficult to assess accurately whether or not they feel their views are listened to and acted on. General practice promotes the protection of residents from abuse, neglect and self-harm, but shortfalls in training must be addressed to ensure this. EVIDENCE: Previous inspection reports indicate that appropriate complaints and adult protection policies are in place. One complaint was received in respect of this service since the last inspection from a former employee. It should be acknowledged that the substance of the complaint related to matters said to have occurred in the past (over three years ago). This was fully investigated by the Local Authority and no further action notified. Most of the people living at Charles House have communication support needs, and a formal complaints procedure has little relevance for them. They are reliant on the vigilance of staff members who know them well to interpret changes in demeanour, behaviour or body language, to alert them to the fact that something is amiss. One resident, who is able to speak for himself, advised the inspector that he knew he could talk to the Manager or members of staff if he had any concerns. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 18 The adult protection policy is linked to local multi-agency guidelines as appropriate. It was noted that available information on staff training indicated that some staff have not yet done adult protection. The Manager advised that this was scheduled within the next fortnight. All staff must receive appropriate training in the protection of vulnerable adults from abuse. This is particularly important where residents are so reliant on staff to understand and recognise signs of abuse appropriately. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents enjoy living in a house that is generally homely and comfortable. Their rooms reflect each person’s individuality and promote their independence, though some would now benefit from decoration or refurbishment. This is also true of the communal areas in the house. The house is kept clean and tidy and a good standard of hygiene maintained. EVIDENCE: A tour of the building was completed. Charles House is an old property that has real character. Some issues identified at previous inspections remain outstanding, in particular maintenance of the conservatory and replacement of the dining room carpet. The Manager advised that the conservatory is scheduled for replacement and he is waiting to hear from the builder to arrange for this to be done. The furniture in this room should also be replaced. These two items have been outstanding in excess of eighteen months, and should be attended to now without further delay. Rooms are generally individual in style and people’s personal effects and possessions are in evidence. These include personal televisions, video / DVD Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 20 players, music systems and computer games, so that people can enjoy private time on their own if they so choose. Staff work hard to ensure that the house is clean and tidy and to maintain a good standard of hygiene. In addition to the dining room carpet needing replacement, the room needs redecoration and the dining furniture replacing. The chair in the adjacent office should also be replaced. The flooring in the kitchen has now been replaced, but the skirting board under the freezer is in need of repair. The laundry should be repainted. The downstairs room with en-suite facilities has been redecorated. The lounge has been redecorated, but the carpet needs cleaning and the furniture should be replaced. The cycle of redecoration and replacement of furniture in residents’ rooms has continued since the last inspection. Three people still require new furniture and two need rooms redecorating, and requirements have been made to this effect at the end of this report. The ceiling & wall on the first floor landing are in need of repair. It was noted that the second floor shower room now had the flooring replaced: the wall on this landing is also in need of repair / redecoration. A new picture board has been installed in the hallway by the front door for displaying staff photographs – some pictures are still outstanding, and this rather defeats the object of the exercise. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 21 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, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are not currently supported by an appropriately trained and qualified staff team and action must be taken to rectify this in order to ensure their safety and quality of care. Recruitment policy and practice support the protection of residents’ welfare. Staff are appropriately supervised, to the benefit of people in their care. EVIDENCE: Information provided in the pre-inspection questionnaire indicates that only 24 of the current staff team are qualified at NVQ level 2 or above. This falls far short of the minimum target of 50 set in Standard 32. The Manager advised that that all staff are currently undergoing Learning Disability Awards Framework (LDAF) training, with the intention of registering for NVQ 2 (where appropriate) when this is complete. Up to date training information is required: this was promised after the inspection visit but had not been received at time of writing this report. Available information showed gaps in training in epilepsy, autism and adult protection training, though (as reported earlier) this is scheduled for midCharles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 22 November. It should be acknowledged that the organisation has a good record of providing training opportunities for staff via a rolling programme, but current shortfalls must be addressed as a matter of some priority. Additional information provided shows that other staff cover a significant proportion of shifts. However, it should be acknowledged that the organisation has built up its staff bank to avoid having to use agency personnel and to promote continuity of care. Staff records were sample-checked, and all necessary documentation was in place. Detailed workbooks provided evidence of appropriate induction training for new staff. Records also show that supervision is up to the required standard – the Manager advised that some of this had now been delegated to senior staff in order to promote their personal development. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 23 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, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The Manager must complete his training to ensure that he is suitably qualified to run the home. The annual quality assurance report is required in order to assess how the views of people using the service have been taken into account. General practice promotes residents’ health safety and welfare, but some items need attention to ensure this. EVIDENCE: The Manager advised that he is still working towards the Registered Manager’s Award and NVQ level 4. He reported that he has completed 4 units, is working on 2 and has 4 more to do. He is also working towards the Assessor’s Award A1 so that he can support members of the staff team working towards gaining NVQ’s. There is an outstanding requirement that a completed application be Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 24 submitted to CSCI to register a manager for the home. This must now be dealt with without further delay. The Manager presents as an approachable individual and appears to have a good working relationship with his team. He said that he gets good support from his line manager and senior personnel within the organisation. Within the organisation each home gets a 6-monthly quality audit performed by one of the other home managers. In addition to providing a separate assessment of the quality of the service, this provides managers with a good learning opportunity by directly observing practice elsewhere. This initiative should be commended. Reports required under Regulation 26 (Care Homes Regulations 2001) are submitted on a regular basis. The Manager advised that the service quality assurance report had been completed, and that a copy would be sent to CSCI. Safety records were sampled. Checks had been carried out on the fire alarm and emergency lighting systems and the fire fighting equipment, and records duly completed. The fire risk assessment has been reviewed and fire drills are being carried out each month. A gas safety check was carried out in September 2006 and Portable Appliance Testing on electrical equipment done in July 2006. The 5-year hard wiring certificate is now due. Tests of water temperatures have been completed regularly. It was noted that the record of fridge and freezer temperatures had several gaps. The COSHH store was secure. Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 3 Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 26 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. 2. Standard YA5 YA6 Regulation 5 15 Requirement Service users’ contracts should be updated to ensure that all information is current. Further develop care plans to set goals with outcomes that can be measured, and review as required. Reviews of care plans must show who takes part and how decisions are made. Develop recording to show how service users have been involved in making decisions and choices 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. Ensure that all PRN (“as required”) medication is supported by a written protocol giving clear guidance as to the circumstances in which such medication should be given. Ensure that all creams and lotions are clearly marked with DS0000016722.V313927.R01.S.doc Timescale for action 31/01/07 28/02/07 3. 4. YA7 YA8 YA12 YA13 12 15 16 (2m-n) 28/02/07 31/01/07 5. YA20 13 (2) 31/12/06 Charles House (Pb) Version 5.2 Page 27 the date of opening 6. YA23 13 (6) Ensure that all staff have 31/12/06 received training in the protection of vulnerable adults from abuse Replace the bedroom furniture 31/01/07 for service users JH, WC and SW. Redecorate service users AM and DB’s bedrooms Clean or replace the dining room 31/01/07 carpet. Complete outstanding maintenance on conservatory. (Outstanding since 21/04/05) Repair skirting board below freezer in the kitchen, and ceiling and walls on first and second floor landings. Make arrangements to meet target of 50 of staff team achieving qualification at NVQ level 2 or above. Forward an up to date staff training and development assessment and plan to CSCI. Complete an application to register a Manager for the Home. Outstanding since 21/04/05 Submit the service’s annual quality assurance report to CSCI. Ensure that checks of the fridge and freezer temperature are carried out each day, and a complete written record maintained. Forward an up to date copy of the home’s 5-year electrical hard wiring certificate to CSCI 7. YA26 16 7. YA28 23 (2) 8. YA32 18 (1a-c) 31/01/07 9. 10. 11. 12. YA35 YA37 YA39 YA42 18 (1a-c) 8&9 24 (1-3) 13 (4c) 31/12/06 31/12/06 31/12/06 31/12/06 13. YA42 13 (4c) 31/12/06 Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 28 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. 2. 3. 4. Refer to Standard YA6 YA20 YA28 YA31 Good Practice Recommendations Develop the use of person-centred approaches in care planning and goal setting practice. Develop Health Action Plans for each resident, so as to promote actively personal health and welfare. Encourage all staff members to provide a photograph for the staff picture board situated by the front door. Ensure that each member of staff has a signed copy of his or her job description maintained on individual personal files. (Not assessed) Charles House (Pb) DS0000016722.V313927.R01.S.doc Version 5.2 Page 29 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. 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