Inspection on 07/02/06 for 225-227 Coleshill Road

This inspection was carried out on 7th February 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

225-227 Coleshill Road 09/06/09

225-227 Coleshill Road 14/06/07

225-227 Coleshill Road 07/09/06

225-227 Coleshill Road 10/08/05

225-227 Coleshill Road 20/01/05

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Coleshill Road, 225 Hodge Hill Birmingham West Midlands B36 8AE Lead Inspector Donna Ahern Unannounced Inspection 7th February 2006 11:30 Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Coleshill Road, 225 Address Hodge Hill Birmingham West Midlands B36 8AE 0121 776 6172 0121 776 6843 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) Elizabeth Fitzroy Support Ann Piri (Acting) Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 10th August 2005 Brief Description of the Service: 225 Coleshill Road is purpose built and owned by Elizabeth Fitzroy Support. It is registered separately from 227 Coleshill Road although both properties are within the same development. The home comprises of two self-contained flats. Both flats within the home have a lounge, open plan kitchen and dining room. All bedrooms are single. Both flats have a laundry, however these are difficult for residents to access, particularly those who use a wheelchair. The second floor of the property has a sleeping in room and office space. The ground and first floors are accessible by a lift. There is a pleasant well maintained garden area. This is accessed via a patio door from the dining room of the ground floor flat. Adjacent to the home is a self-contained flat (225a) for one service user who receives support from staff at the main home. There is parking in the grounds of the property. The home is located on a bus route and is close to shops, churches and a variety of leisure facilities are within easy commuting distance. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The previous inspection took place in August 2005 when most of the core standards were assessed. The focus of this inspection was to monitor progress on the previous requirements. Temporary management arrangements were in place in both homes (225 and 227 Coleshill Road) in August 2005. Since then a new manager has been appointed who will manage both homes. She is currently in the process of registering with CSCI. The two assistant managers left in December 2005 both for promotion positions. New assistant managers have been appointed in both houses. There have been some moves towards the two homes working more closely together and it is anticipated that this will improve the service for all thirteen residents. The homes remain as two separate registrations. This report relates to the inspection of 225 Coleshill Road. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. Staff records were examined, and Health and Safety records were inspected. The inspector had the opportunity to talk to the manager and four care staff. This report should be read in conjunction with the inspection report of August 2005 What the service does well: Residents and staff interacted well. There was evidence of good attention to residents personal care needs. The manager and staff team have been proactive in requesting the support of other professionals so they can meet resident’s needs. Health and Safety matters are generally well managed. The layout of the home, which includes two three, bedded flats and a self contained flat provides comfortable, homely and a safe environment for residents. There is a large, very pleasant, well-maintained and accessible garden. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The Statement of Purpose and Service User Guide were in the process of being updated so that prospective residents have the required information so they can make a choice about the home they live in. EVIDENCE: There have been no new admissions since the previous inspection and there were no vacancies. The home has an admission procedure. The Statement of Purpose and Service User Guide were in the process of being reviewed and updated to reflect the staff and management changes. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 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 and 9 Further development of residents care plans was required so that an up to date plan of care is in place so that resident’s needs, aspirations and goals are clearly documented and monitored. Some further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: The previous inspection identified that the care plans required further development and a review of the structure and layout. The manager stated that all residents care plans were to be reviewed and she had commenced this process. One care plan was nearing completion and had been completely revised with a new format and layout and the process of cross referencing risk assessment to the care plans had commenced. This care plan was assessed. It was advised that where the care plan gives information about the resident’s personal care the care plan must be specific about the level of support required and it should include how staff can support the person to be more independent. The manager stated that each care plan would be developed in conjunction with the respective keyworkers. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 10 A number of risk assessments were assessed including risk assessments for bathing and showering many of the risk assessments seen could be combined so that information is clearer. There must be evidence that the control measures in place have been fully reviewed Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 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): EVIDENCE: Not assessed these standards were assessed in full at the previous inspection August 2005. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 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): 18 and 19 Residents receive a good level of support with their personal care and healthcare needs. The home must improve the recording of residents healthcare so that they can evidence that their health care needs have been met. EVIDENCE: The care plans required some further development regarding how to support residents with their personal care needs. The arrangements for supporting one resident when they have a shower had been reviewed as required at the previous inspection. The Manual handling assessment for one resident had been revised the assessments for the other residents required review. The previous inspection report highlighted some of the difficulties the manager and staff team had experienced providing a consistent staff team for the one resident who lives in 225 (A). Providing a staff team that is reflective of the person cultural background and same gender is very important to the resident. Some progress had been made the manager recognised that there was further work to do. She felt that by the two homes 225 and 227 Coleshill Road working closer together there should be a better use of staffing resources, which should be of a benefit to the resident in Flat 225 (A). Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 13 The manger stated that work was taking place to residents “OK Health Checks” which are a health action plan format. So that the format is fully used and the action plan section completed and evidence that resident’s health care needs are monitored. Two of the residents have had health complications and changing needs. Through discussion with the manager, staff and sampling of information there was evidence that the staff team are committed to providing good care and appropriately involve other professionals so that residents receive the required support. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 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): 22 and 23 The complaints and adult protection procedure safeguards residents. Staff training had been actioned so that residents are supported by an informed staff team who can safeguard residents from abuse. EVIDENCE: Only one of the seven residents would be able to verbally raise a concern or a complaint all other residents are reliant on the staff team to promote and protect their well being. There was a complaint policy and procedure in place, which were assessed as meeting the standard at the previous inspection. The provider had received no complaints. The organisations Adult Protection Procedure was assessed at the previous inspection and it was requested that and the appendix (iii) was completed so that it contained a flow chart and boxes for relevant contact details in the event of a protection matter being identified in the home. This had been actioned. There was a copy of the Birmingham Multi-agency Guidelines available to compliment the organisations own policy and procedure. The manager stated that Adult Protection training had been provided in January 2006 and further sessions were planned for February and March 2006. An incident had occurred in the home, which required the implementation of the adult protection procedures and a referral to Social Care and Health. It was Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 15 positive that the manager had acted appropriately and without prejudice to safeguard residents and staff. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 16 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 and 30 Residents live in a homely, comfortable and safe environment. EVIDENCE: 225 Coleshill Road consist of two, three bedded flats and an adjacent flat for one service user. The home was a purpose built property and therefore meets all the required standards. A previously raised concern was access to the laundry for residents; the inspector was informed that the layout of the laundry was still under review. The two flats were well maintained, accessible and safe and free from offensive odours. They meet the current needs of residents. The physical standards of flat 225 (A) were not assessed at this inspection. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 17 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, 33, 35 and 36 Staffing levels must be reviewed so that the home has an effective staff team, with sufficient numbers so that residents are supported by an effective staff team. Staff must receive regular supervision so that residents are supported by a well-supervised staff team. EVIDENCE: Staffing levels are three staff on duty at core times when all the residents are at home. This allows one staff in each flat and one staff member going between the two flats to support. The rota indicated that there was some flexibility with the rota and at time four staff are on duty to support evening activities. At night there is one person doing a waking night shift and one person on call on a sleeping in shift between the two registered homes 225 and 227. One week the person is based in 225 and the following week they are based in 227. The previous report required that a review of staffing levels must take place, as two staff are required at core times on each flat. The manager stated that the Operations Manager had completed a comprehensive review of staffing and residents needs that had been forwarded to the relevant placing authorities. A response from the respective authorities remained outstanding and the Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 18 manager advised that the provider was to address this with the different placing authorities. CSCI must be kept informed of developments. Staff training records were examined and required some updating to reflect training received. Staff indicated that training in mandatory areas required updating this is a concern and remains outstanding from the previous inspection. The organisations’ training is now arranged at a regional level. There was evidence that the training was not as well organised as when it was managed at a more local level. Training must be provide for the newly appointed assistant managers so that they have the skills to undertake their new role and can support the development of the home. Supervision records were assessed and indicated infrequent supervision over the last twelve. This remains outstanding from the previous inspection. Regular supervision must be provided for all staff at least six per year with records kept. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 Some health and safety matters required attention so that resident’s safety and welfare is protected. EVIDENCE: The registered manager resigned in October 2004. There have been temporary management arrangements in place. The assistant manager acted up in the manager position for a protracted period she left the home for promotion with another organisation in December 2005. A new manager was appointed in September 2005. An application to register the manager was being processed by CSCI and the interview is arranged for February 2006. The manager will be the registered person for 225 and 227 Coleshill Road. Two assistant managers have been appointed, one for each house. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 20 The home has gone through a very unsettled time with a lot of staff and management changes. Feedback from staff was very positive about the current management of the home. Staff said that they feel like “things will get done”. Whilst the care practice is generally good there is a need for development of the home, particularly around resident care planning and health documentation. So that the provider can demonstrate that residents assessed needs are being met. The manager had revised the fire evacuation procedure this required some additional information including how each residents would be supported to evacuate the home. Staffing levels required review as raised in previous reports and in section 33 of this report. Risk assessments regarding the care and support of residents required some further development as raised under standard 9 of the report. Loose sheets for the recording of any accidents or incidents were still in use. The recording sheet is lengthy and the use of loose sheets is problematic as there is the potential for information to become misplaced. It was strongly advised at the previous inspection that that this system is revised and consideration given to the using of a bounded accident book with numbered pages. This was still under review Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 21 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 2 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 X X 2 X X X X 2 X Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(c) sch 1 Requirement Some updating of the Statement of Purpose and Service User Guide was required. Care plans required some further development. Information and guidance added to the care plan must be dated and signed. Risk assessments required further development. Manual handling risk assessments required further development. Health Action plans required further development The registered person must inform CSCI of the outcome of the reassessment of residents needs and the review of staffing levels. CSCI must be informed of the staffing assignment for the home and how the new management structure will work. All staff must receive training in Adult Protection, Epilepsy, Person Centred Planning, Disability Equality DS0000017174.V283030.R01.S.doc Timescale for action 31/03/06 2. 3. 4. 5. 6. 7. YA6 YA6 YA9 YA18 YA19 YA33 15(1) (2) 15(1)(2) 13(4) a-c 13(5) 12(1)(a) 13(1)(b) 18(1)(a) 31/05/06 31/03/06 31/03/06 28/02/06 31/03/06 31/03/06 8. YA35 18(1)(c) 31/05/06 Coleshill Road, 225 Version 5.1 Page 23 9. YA36 18(2) 10 YA42 23(40) training and Race Equality. Refresher /updates on mandatory training. All staff must receive regular supervision meetings at least six sessions per year with records kept. Profiles detailing how residents are supported to evacuate the home were required. 31/03/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA42 Good Practice Recommendations It was strongly advised that the accident recording system is revised and consideration given to the use of a bounded accident book with numbered pages. Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coleshill Road, 225 DS0000017174.V283030.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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