Inspection on 26/09/07 for Chesterberry

This inspection was carried out on 26th September 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chesterberry 09/03/06

Chesterberry 09/09/05

Chesterberry 23/02/05

Chesterberry 25/08/04

Chesterberry 10/03/04

Similar services:

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

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Chesterberry 766 Chester Road Erdington Birmingham West Midlands B24 0EA Lead Inspector Sarah Bennett Key Unannounced Inspection 26th September 2007 09:50 Chesterberry DS0000016724.V346370.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 Chesterberry DS0000016724.V346370.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. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chesterberry Address 766 Chester Road Erdington Birmingham West Midlands B24 0EA 0121 386 2290 F/P 0121 386 2290 heather.andrews@bid.org.uk 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) Birmingham Institute for the Deaf Heather Louise Andrews Care Home 7 Category(ies) of Learning disability (7), Sensory impairment (7) registration, with number of places Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (without nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Learning Disability (LD 7) - Sensory Impairment (SI 7) Service users must be under the age of 65. The maximum number of service users who can be accommodated is 7. 2. 3. Date of last inspection 19th & 20th February 2007 Brief Description of the Service: Chester Berry is registered to provide accommodation, care and support for seven people who are profoundly Deaf and have additional needs. The service is owned, managed and staffed by Birmingham Institute for the Deaf. The property has recently been refurbished and is a large, detached periodstyle house situated on the main Chester Road in the Erdington area of Birmingham. There are seven bedrooms (five of which have en suite facilities), one lounge, one sitting/activity room, kitchen, laundry room, one bathroom (which can be shared by up to two people), one WC, one staff/visitor WC, conservatory and staff facilities (one sleep in room and office). The home is equipped with specialist equipment for Deaf People including flashing door bell/phone alerts, fire alarm systems and Mincom/fax, and provides access to interpreting support and further equipment when required. All equipment systems are linked to pagers for staff. To the rear of the property is a very large private garden, with patio area and garden furniture and lawned areas with shrubs and flowerbeds. At the front of the house there is limited off-road parking. The Home has its own vehicle, but the area is also well served by public transport. The shopping areas of Wylde Green and Erdington are both close by and include a wide range of local amenities. The statement of purpose states that the fees charged range between £1047.26 to £1505.00. These include 24 hour staffing, food and drink, laundry, support to access medical appointments, heating, lighting and water, social and community support and communication support. Dry cleaning, hairdressing, Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 5 private phone installation and calls and network connection and charges are not included in the fees. The inspection report is available in the home for visitors to read if they wish to. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over one day; the home did not know the inspector was going to visit. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home – Annual Quality Assurance Assessment (AQAA). Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. The people who live at the home were spoken to. A British Sign Language (BSL) interpreter was there for part of the visit to assist in communication with the people who live there and staff who are Deaf. What the service does well: Each person living there has a care plan and risk assessments so that staff know how to meet the person’s needs and help to keep them safe when they are taking risks. People are supported to meet with others in the Deaf community and staff recognise that this is important to them. They are also supported to meet with people and make friends with those who are not part of the Deaf community. The people living there can go out every day if they want to and are supported to do the things they like doing. The people living there said they liked the food. One person said they help with cooking and baking and buys the food from the shop. A relative had written to the staff and said, “Thank you for all you do for my son.” One person said, “It is big and beautiful here and the staff are nice.” Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 7 The staff that work there know how to communicate with the people living there using British Sign Language that they understand. What has improved since the last inspection? What they could do better: Any allegation of abuse must be reported in line with the local multi-agency guidelines on the protection of vulnerable adults to ensure that the people living there are safeguarded from abuse. Staff should have refresher training in adult protection and the prevention of abuse so they know when to report any incidents of abuse and ensure the people living there are safeguarded. Food records should be completed regularly and show that people are being offered a healthy diet to ensure their health and well being. Where appropriate individual’s bowel movements should be recorded regularly and where needed action taken so that the person’s health needs are met. The laundry and infection control procedures should include details on how the risk of cross infection is to be minimised until a wash hand basin is installed. A wash hand basin should be installed in the laundry to minimise the risks of cross infection. An extractor duct should be fitted to the tumble dryer so that it can be used to dry people’s clothes. If their clothes have to be taken to the launderette to be dried this should not affect the activities that people do and if needed extra staffing should be provided so this does not happen. There should be at least six staff meetings per year and all staff should have regular formal supervision with their manager. This will help staff have updated information as to how to support the people living there and the policies and procedures of the home and organisation. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 8 Monthly visits should include asking the views of the people living there and their friends and family to ensure that their views underpin the development of the service. 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. The summary of this inspection report can be made available in other formats on request. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 9 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 Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need so they can make a choice as to whether or not they want to live there and if their needs can be met. Arrangements ensure that individual’s needs are assessed to ensure that they can be met. EVIDENCE: A copy of the updated statement of purpose was provided at the inspection. This had been updated to include the changes to the service provided. Previously the people who now live there lived in two separate care homes. Five people lived at this address and the other two people lived at Maple Court in Erdington. This home had been refurbished to accommodate seven people and has one staff team where previously there were two. During refurbishment people moved out to temporary accommodation in Sutton Coldfield and the last inspection took place there and at Maple Court. The statement of purpose included the relevant and required information so that any prospective service users would have the information they need so they choose whether or not they want to live there. It included the communication skills of the staff and stated that all staff are required to Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 11 already possess or work towards British Sign Language Level II so that they are able to communicate with the people living there. Records sampled showed that a full assessment of individual’s needs was carried out to ensure that the individual’s needs could be met at the home. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person has a care plan so that staff know how to support individuals to meet their needs and achieve their goals. The people living there are supported to make decisions about their lives and take risks within a risk assessment framework so ensuring their health and well being. EVIDENCE: Three records of the people who live there were sampled. The manager said and records showed that individual’s care plans were being reviewed and updated as necessary. Each person had a care plan that detailed how staff are to support them to meet their needs and achieve their goals. These included their needs relating to communication, personal care, support during the night, health, dietary, the management of their money, making choices, leisure, social and emotional needs. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 13 Records sampled showed and people said that they are able to choose what they eat and drink, what they wear, what they do and where they go. People were observed making their own drinks if they were able to, as they wanted them and making choices about how they spent their day. Records included individual risk assessments. These were called ‘Balancing Risk and Happiness’ as it is important that people take risks, when doing an activity for example benefits the individual so outweighing the risks involved. These stated how staff are to support the person to minimise the risks whilst ensuring that people can be independent and take risks in their daily lives. Some people sometimes display behaviour that can challenge and may affect the other people who live there. Risk assessments were in place that stated how staff are to support the individual to minimise the impact of their behaviour on the other people living there. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living there experience a meaningful lifestyle. Generally arrangements ensure that people are offered a varied and healthy diet that ensures their health and well being. EVIDENCE: Some people go to college during the week and do computer courses. Records sampled showed that people are supported to take part in a range of activities inside and outside the home. These include shopping, going to the park, doing gardening, cleaning their bedrooms, doing their laundry, bowling, going to cafés, pubs, restaurants, going to church, the cinema, swimming, going to the barbers or hairdressers, arts and crafts, using the computer, playing on their games console and going on day trips to places of interest. The people living there have the opportunity to go out at least once a day. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 15 Some records showed that people made the choice not to go out on some days. Some people went out with a member of staff to buy a wheelbarrow for the garden. Some people went to the local shops and some people went out for lunch. Later in the afternoon some people went to the cinema and others went bowling. Last October the people living there went to Disneyland, Paris supported by staff. People had taken photographs of this and some people had these framed and displayed in their bedrooms. They said that they had a good time. As people moved into the new home this year they had not been away on a long holiday. However, they all went to a hotel in Manchester for a long weekend. People said that they had a good time and did the ‘Old Trafford’ tour, went to a Dr Who exhibition and went to the Deaf church. One person used to have a caravan in Stratford upon Avon where they and the other people living there used to go for weekends. Unfortunately during the summer it was flooded and had been ‘written off’. The person’s family are looking at the insurance and the possibility of them getting a new one. The manager said they supported the person to go and see the caravan after the floods. The manager said they seemed to have accepted it had gone and no longer talk about it. Records showed and people said that they are supported to stay in contact with their family and friends. One person had some friends visit at lunch- time and they went to the pub for lunch with them supported by staff. They had met these friends on holiday and staff had supported them to keep in contact with them. Some people visit their relatives either regularly or when they choose to, their family visit the home and people are supported to send messages by fax or using the minicom to their family and friends. Records showed that staff support people to buy cards and presents for their family and friends on special occasions. People used to go to the Deaf Centre in Ladywood, Birmingham. This had recently been refurbished and is now a national resource for the Deaf. The people living there had been supported to go to the opening of this and had an opportunity to meet Princess Anne. Records showed that people were supported to dress appropriately for this occasion. People plan to use this centre in the future where they will have an opportunity to meet with their friends and others from the Deaf community. Records showed and people said they are supported to be as independent as possible. Individuals are encouraged to take part in household chores including doing their laundry, cleaning their bedroom and changing their bed, making their breakfast and lunch and making drinks. Food records sampled showed that people are offered a varied diet that includes some fruit and vegetables. However, only on a few days had people Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 16 had the recommended five portions of fruit and vegetables for a healthy diet. The manager was aware that not all the food records had been completed and said that she would remind staff about this. There was a large bowl of fresh fruit in the kitchen that people were observed eating when they wanted it. Where appropriate people were offered food that reflected their cultural background and were supported to go and buy the foods they liked from specialist shops. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 17 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. 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 this service. Generally arrangements are sufficient to ensure that individuals personal care and health needs are met so ensuring their well being. The management of the medication protects the people living there so they get the medication they are prescribed at the right time. EVIDENCE: Care plans stated how staff are to support individuals with their personal care and to meet their health needs. Records sampled listed the toiletries that the person uses to ensure that staff know what individual’s preferences are and the toiletries the person has are suitable for their skin and hair type. People said that they buy their own clothes and staff support them with this when needed. The people living there were dressed in good quality clothes that were appropriate to their age, the weather, the activities they were doing and their cultural background. Records sampled showed that staff had an awareness of how to care for a person’s skin and hair depending on the individual’s racial background. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 18 Records showed that where appropriate health professionals are involved in individual’s care to ensure their health needs are met. Records of appointments are kept and any advice given from professionals so that staff know how to support the individual. Records showed that people have regular health checks with the dentist, optician and chiropodist where appropriate. The people living there are weighed regularly. Records showed that individual’s weight had not increased or decreased significantly, which could be an indicator of an underlying health need. One person’s care plan stated that they are prone to constipation and staff need to record when the person has a bowel movement so they can take appropriate action where needed to relive the constipation. Their bowel records in August indicated that they had not had a bowel movement for seven days but there was no record of any action taken. This should be recorded regularly and where appropriate action taken so that the person’s health needs are met. Boots supply the medication in blister packs using the monitored dosage system, which makes it easier for staff to ensure they give each person their right medication at the right time. Some people are prescribed ‘as required’ (PRN) medication. A protocol that was signed by their GP was in place that stated when, why and how much of the medication should be given to ensure that they get the medication only when they need it. Medication Administration Records (MARS) had been signed appropriately and these cross-referenced with the blister pack indicating that medication had been given as prescribed. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 19 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. 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 this service. Arrangements ensure that the views of the people living there are listened to and acted on. Arrangements are not always sufficient to ensure that the people living there are protected from abuse, neglect and self-harm. EVIDENCE: Details of how the people living there or their family and friends can make a complaint if they are unhappy with the service provided is displayed in the home and is included in the statement of purpose. It included details of how to contact the Commission if they wish to make a complaint. There had been no complaints made to the home or the Commission in the last twelve months. Staff said and cards received showed that they have received compliments from the families of the people living there. There was a message in the staff communication book from the manager asking staff to read the Code of Practice for the Mental Capacity Act (MCA). The manager has received training in the MCA and had identified that staff also need to have this training so they are aware of how they support people if they have the capacity to make their own decisions or whether they need support from others to do this. Three finance records of the people who live there were looked at. Each person has their own bank accounts and their benefits are paid into these. The people living there said that staff support them to go to the bank when they want to Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 20 so they can withdraw their money. When people were living in the temporary accommodation there was a burglary during the night and some people had some of their money stolen. This was reimbursed to them by BID and the incident reported to the police and the Commission. The manager said that following this they have reduced the amount that people withdraw at one time so there is less money kept in the home. The money kept for individuals crossreferenced with their records. Receipts were available of the purchases they had made and all their money had been spent on personal items. The manager said that a member of staff was currently suspended. Two members of staff had alleged that they had abused one of the people living there. This allegation was made at the end of August when the manager was on holiday. Staff alleged that it happened on the Wednesday evening but did not report it to the manager until they returned from holiday the following Monday. This had not been reported to the Commission or the local authority Adults and Communities Department. Local policies are in place that requires agencies to work together in ensuring that vulnerable adults are safeguarded. If allegations are not reported to other agencies this cannot happen. The manager said she is investigating this and has already taken written statements from staff to assist with this. The manager said that they did not report it to Adults and Communities as the person does not have an allocated social worker and it is difficult to contact a social worker. The manager was advised to contact the duty social worker as a matter of urgency. Although the person is safeguarded, as the member of staff has been suspended excluding other agencies from being involved may prevent the investigation from being undertaken in a fair and equitable way. Records showed that staff had received training in adult protection and the prevention of abuse. However, staff may need a refresher in this to ensure that they report allegations of abuse when they happen so that the people living there are safe. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people live in a homely and comfortable environment that meets their individual needs. Arrangements are not sufficient to ensure that the risks of cross-infection are minimised as much as possible, which could affect the well being of the people living there. EVIDENCE: The home had been refurbished, furnished and decorated to a high standard making it a comfortable and homely place to live. Curtains had been fitted to the conservatory ceiling to shield the sunlight when sitting at the kitchen table. Five of the bedrooms have an en suite shower. The other two people prefer to have a bath and share a bathroom that is near to their bedrooms. People’s bedrooms were well decorated and people said they had been involved in choosing the colour of these and had chosen their new furniture. Bedrooms were personalised, one person is particularly interested in stars and has their Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 22 ceiling painted with these, which lights up at night so they can lie in bed looking at them. One person said they had bought their own pictures for their bedroom and had painted one of the canvasses that were on the wall. Photographs were displayed around people’s bedrooms of their family, friends and holidays they had been on. The people living there said they had a key to their bedroom. The home is equipped with specialist equipment for Deaf People including flashing door bell/phone alerts, fire alarm systems and minicom/fax, and provides access to interpreting support and further equipment when required. All equipment systems are linked to pagers for staff. Where people had an additional visual impairment their bedroom was painted in contrasting colours to assist them in finding their way around independently. The home was clean and free from offensive odours making it a pleasant place to live. The laundry room is situated on the first floor. At the visit by the Commission’s Registration Team in June prior to the home being registered it was found that the washing machine did not have a sluice cycle and there was not a wash hand basin in the laundry room. The manager said that as none of the people would be living there had incontinence needs the risk of infection would be minimised. The Registration Inspector advised them to ensure the laundry and infection control procedures addressed these issues and a wash hand basin be installed. The manager said these procedures were not yet completed. It was disappointing that the wash hand basin had not been installed in the laundry. There was a gel hand wash for staff to use to reduce the risk of infection in the laundry. The manager said that a plumber was coming to give a quote because the previous quote had been too high. The tumble dryer could not be used, as an extractor duct needed to be fitted to it. The washing had to be hung out on the washing line and the manager said if they needed to they would use the launderette to dry clothes until this is fitted. If this is the case this should not impact on the activities that the people living there do and if needed extra staffing should be provided so this does not happen. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that a well trained, supported and qualified staff team support the people living there to meet their needs and achieve their goals. The recruitment practices protect the people living there to ensure that ‘suitable’ people are employed. EVIDENCE: The AQAA stated that 82 of staff have achieved National Vocational Qualification (NVQ) level 2 or above in Care. The other staff are working towards this qualification. This exceeds the standard that at least 50 of staff have achieved this so ensuring that they have the skills and knowledge to meet the needs of the people living there. The manager said that the staffing has improved now that all the staff work in one home and are not spread across two homes. The manager said that this has improved the consistency of support that staff give to the people living there and that staff work better as team. The manager said that one member of staff left in August this year. This post has now been recruited to. One Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 24 member of staff is absent due to long-term sickness and another member of staff was suspended pending investigation. Rotas showed that vacant shifts are covered with permanent staff doing extra hours and BID relief staff. Minutes of staff meetings showed that there had been five meetings in the last year. The standard is that there should be at least six staff meetings per year so that staff have updated information on how to support each person living there and the policies and procedures of the home and organisation. Three staff records were sampled. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken to ensure that ‘suitable’ people are employed to work with the people living there. Records sampled showed that when staff started working at the home they had an induction so they knew how to support the people living there to meet their needs. Records showed that staff had received training in British Sign Language (BSL) levels 1 and 2, adult protection and the prevention of abuse, cultural awareness, data protection, behaviour management, epilepsy, infection control, food hygiene, health and safety, fire safety, medication, first aid and moving and handling. Some people require refresher training in first aid and food hygiene. The manager said that she had identified who needs this and had booked this training so that all staff are up to date. Most staff had completed medication training up to NVQ level 2 standard. Epilepsy training was booked for the following day for staff to attend. Staff records sampled showed that staff had not received regular formal, recorded supervision sessions. However, records indicated that the frequency of these was improving. Each of the staff had a performance review this year with their manager. During these their training and development needs were identified for the coming year and any areas for improvement was stated and targets set to enable them to achieve this. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements ensure that the people living there benefit from a well run home. Arrangements are not sufficient to ensure that the people living there can be confident that their views underpin all self-monitoring, review and development of the home. The health and safety of the people living there is promoted and protected. EVIDENCE: The manager is registered with the CSCI and is undertaking the Registered Managers Award (RMA). She said she has another assignment to complete for Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 26 this and then will need to be observed. Her assessor was due to visit the following week. The organisation, BID has an internal quality assurance system which includes the monthly visits from the Operations Manager. Reports of these visits showed that they focused on whether the required records were in place and not on the views of the people living there or their quality of life. These should ask for people’s views and those of their family and friends so they can be confident that their views underpin the self-monitoring, review and development by the home. There is an annual finance audit that includes looking at finance records of the people who live there. Fire records showed that staff test the fire equipment regularly to make sure it is working. Staff had received training in fire safety so they know how to prevent fires from starting. Regular fire drills take place so that the people living there and staff know what to do if there is a fire. Staff test the water temperatures tested weekly to make sure they are not too hot or cold and people are not at risk of being scalded. Records of these showed that at the last test they were within the recommended safe limits. Staff test the fridge and freezer temperatures daily to ensure they are within the safe limits so that food is stored safely. Records showed they were within the safe limits to ensure that the risk of food poisoning is minimised. Records showed that an electrician had tested the portable electrical appliances in July this year to make sure they are safe to use. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 1 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 (6) Requirement Any allegation of abuse must be reported in line with the local multi-agency guidelines on the protection of vulnerable adults to ensure that the people living there are safeguarded from abuse. Timescale for action 28/10/07 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. Refer to Standard YA17 YA19 Good Practice Recommendations Food records should be completed regularly and show that people are being offered a healthy diet to ensure their health and well being. Where appropriate individual’s bowel movements should be recorded regularly and where needed action taken so that the person’s health needs are met. Staff should receive refresher training in adult protection and the prevention of abuse so they know when to report any incidents of abuse and ensure the people living there are safeguarded. DS0000016724.V346370.R01.S.doc Version 5.2 Page 29 3. YA23 Chesterberry 4. YA30 The laundry and infection control procedures should include details on how the risk of cross infection is to be minimised until a wash hand basin is installed. A wash hand basin should be installed in the laundry to minimise the risks of cross infection. 5. YA30 6. YA30 7. YA33 8. 9. YA36 YA39 An extractor duct should be fitted to the tumble dryer so that it can be used to dry people’s clothes. If their clothes have to be taken to the launderette to be dried this should not impact on the activities that people do and if needed extra staffing should be provided so this does not happen. There should be at least six staff meetings per year so that staff have updated information as to how to support the people living there and the policies and procedures of the home and organisation. All staff should receive formal, recorded supervision with their manager at least six times a year to ensure they are supported to meet the needs of the people living there. Monthly visits should include asking the views of the people living there and their friends and family to ensure that their views underpin the development of the service. Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Chesterberry DS0000016724.V346370.R01.S.doc Version 5.2 Page 31 - 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!