Inspection on 07/09/06 for 225-227 Coleshill Road

This inspection was carried out on 7th September 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 18 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 07/02/06

225-227 Coleshill Road 10/08/05

225-227 Coleshill Road 20/01/05

Similar services:

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, 225-227 Hodge Hill Birmingham West Midlands B36 8AE Lead Inspector Sarah Bennett Unannounced Inspection 7th September 2006 09:30 Coleshill Road, 225-227 DS0000017174.V310381.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 Coleshill Road, 225-227 DS0000017174.V310381.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. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coleshill Road, 225-227 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 Mrs Anne Piri Care Home 13 Category(ies) of Learning disability (13), Physical disability (13) registration, with number of places Coleshill Road, 225-227 DS0000017174.V310381.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 7th February 2006 Brief Description of the Service: 225 – 227 Coleshill Road are purpose built and owned by Elizabeth Fitzroy Support. Each of the properties comprise of two self-contained flats. The flats have a lounge, open plan kitchen and dining room. All bedrooms are single. There is a laundry in each of the flats, however apart from one in 225 that has been adapted these are difficult for residents to access, particularly those who use a wheelchair. The second floor of each 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 and a newly built snoozelen room. This is accessed via a patio door from the dining room of the ground floor flat in 225. Adjacent to the home is a self-contained flat (225a) for one service user who receives support from staff at the 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. The CSCI inspection report is available in the home for visitors to read if they wish to. The range of fees charged is not known, as this information was not asked for at this visit. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. One inspector carried out the unannounced fieldwork visit over eight hours. This was the homes key inspection for the inspection year 2006 to 2007. The staff on duty were spoken to. Conversations with some service users were limited due to their complex needs and limited verbal communication. The inspector met with nine service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. Since the last inspection 225 and 227 have been registered as one home. There is one Registered Manager and in each home there is an Assistant Manager. What the service does well: What has improved since the last inspection? Staff have worked hard to make individuals care plans better. This helps staff to know how to support the people who live in the home to meet their needs and achieve their goals. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 6 Health Action Plans had been improved so it was easier to see what each person needed to stay healthy and what health services they need to use. Staff had training on epilepsy so that they can meet the needs of individual service users better. Staff had training on how to stop abuse to help them to keep service users safe from harm. The Manager has been registered with the CSCI. Staff said that the Manager makes sure that staff get the training they need to do their job so that they can meet the service users needs. 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, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 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, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 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, 5 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have most of the information needed to make an informed choice about whether or not they want to live at the home. Each service user has an individual contract so that they are aware of the terms and conditions of their stay at the home. EVIDENCE: The service users guide seen in 225 included the information that is required in this document. However, it had not been updated with the change of Managers. It had been produced using pictures making it easier to understand. The Assistant Manager said that this may have been updated but an updated copy could not be found. The statement of purpose of the home included all the relevant and required information. The service users have lived at the home for a number of years and there had been no recent admissions therefore standard 2 relating to assessment could not be assessed. Service users records sampled included a contract of the agreement between the individual and Elizabeth Fitzroy Support. This was produced using pictures making it easier to understand. It stated the terms and conditions of their stay at the home including the room allocated, what the fees cover, their rights, Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 9 how to make a complaint and how to contact the CSCI. A representative of the service user and the previous registered manager had signed the contract. Coleshill Road, 225-227 DS0000017174.V310381.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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a care plan so that staff know how to support them to meet their needs and achieve their goals. Service users are supported to make decisions about their day-to-day lives and are consulted on all aspects of life in the home. Service users are supported to take risks within a risk assessment framework. These need to be reviewed to ensure that relevant risks are assessed. EVIDENCE: Four service users records were sampled. These included an individual care plan. These were detailed and written in a way that was centred on the individual, the things they like doing, the things and people that are important to them and what others like and admire about them. They included pictures and photographs making the care plan easier to understand. Service user meetings are held in each home. Because of the limited verbal communication of the people who live in 225 staff look at areas where they are supporting people and how they can ensure that they can support them to make decisions about their lives. This includes getting to know people and Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 11 picking up on non-verbal communication and what this means and talking to relatives and other significant people in the individual’s life. Care plans sampled included details of how the individual communicates using non-verbal communication for example that they are hungry, thirsty, that they want to go to bed, have a bath or be left alone. In 227 minutes of service users meetings showed that they had discussed menus- eating healthy foods and trying different foods, activities and starting to plan any special activities for Christmas. Staff were observed asking service users what they would like to do, where they wanted to go and what they wanted to eat or drink. Staff knocked on service users bedroom doors before entering and asked service users if the inspector could look in their bedroom. Service users records sampled included individual risk assessments. These included assessing the risk of using the kitchen, bathing, going swimming, going on holiday, sitting in the sun, the individuals’ behaviour, mobility, finances, health needs, using the snoozelen room and travelling in the home’s vehicle. Several risk assessments required reviewing to ensure that they are still relevant. They must be updated if they are not to ensure that appropriate action is taken to minimise risks. Coleshill Road, 225-227 DS0000017174.V310381.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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally arrangements in place ensure that people living in the home experience a meaningful lifestyle. Service users are offered a healthy diet and enjoy their meals. EVIDENCE: Service users go to day centres, colleges and do voluntary work if they are able to. Service users records sampled showed that they watch TV, listen to music, go to car boot sales, pubs, restaurants, barbers, shopping, the Nature Centre, parks, play games and go to church. One of the service users records sampled for August 2006 showed that apart from going to the day centre they had been out of the home twice. Staff said that during August service users were on holiday from the day centre for two weeks and had been out a lot, however, this was not recorded. The service users care plan stated that they did not get anything out of watching TV but there were several entries stating they had watched TV. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 13 A snoozelen room had recently been built in the garden. Service users were supported to use this room during the day and staff said they hoped that it would be of benefit to several service users. Vehicles are provided to enable service users to access the local community. They also use the ‘Ring & Ride’ service and public transport where they are able. Some of the service users in 227 had been on holiday to Blackpool in August. Staff said that several of the service users supported by staff are going to a hotel in Blackpool in October. One of the service users went on holiday to Wales in June. Records sampled showed that service users are supported to maintain links with their family and friends. Service users said that they could visit their family and friends and telephone them if they want to. Records showed that service users had been involved in household tasks where possible and encouraged to help with cooking meals. Service users were observed making their own drinks with support where needed. Food records sampled showed that a variety of food is offered that includes fruit and vegetables. Food offered to individuals was appropriate to their cultural background. Where service users had refused food this was recorded and appropriate action taken to investigate health needs that were related to this. Care plans included details about the foods that individuals like and dislike and how they like their drinks to be made. Adequate food stocks were provided in each flat. These included fresh fruit and vegetables. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Generally the health needs of service users are met but improvement is needed to ensure that all are met. Generally the arrangements for the management of the medication protect service users. EVIDENCE: Service users care plans sampled detailed how staff are to support them with their personal care. They used pictures so it was easier to understand. Service users records sampled showed that where individuals had health needs staff had observed changes in their health and reported these. Appropriate action had been taken to refer the individual to health professionals to ensure they receive any treatment needed. Records showed that staff had supported the individual to be as comfortable as possible. This included staying in bed to ensure they had the rest they needed and having a long, relaxing bath. Service users were well dressed appropriately to their age, their cultural background and the activities they were doing. Each person had their individual style of hair and dress. Staff said that service users had their haircut at local barbers or hairdressers. It was a sunny day and staff were observed supporting service users to put on sun cream when going out in the garden. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 15 Service users records sampled included moving and handling assessments. These stated the support required from staff to assist the individual with their mobility whilst reducing the risks of injury to the service user and staff. An ‘OK Health Check’ had been completed for each service user. This assessed the health needs of each individual, what support from staff they needed to meet their health needs and what health services they needed to access. Records sampled showed that where appropriate health professionals are involved in the care of service users. These included the Community Nurse, Psychiatrist, Neurologist, Epilepsy Nurse, Dietician and the Asthma Nurse. Records sampled included weight charts for each individual. For two of the service users these were recorded monthly and showed that individuals weight was stable. For one of the service users their records showed that they had gained 10lbs in five months. For one of the service users there was not a record since June 2006. The Dietician had recommended in March 2006 that the individual lose 10 of their weight by November 2006.Between April and June their weight record stated that they had gained weight. The Dietician had recommended that staff receive ‘In Proportion’ training on food portion sizes and that the individual go to the weight clinic monthly. Staff had not received this training and the service user had not been to the weight clinic since April 2006. Generally records sampled showed that service users had regular check-ups with the Dentist and Chiropodist. One of the service users ‘OK Health Check’ stated that they had regular dental checks and that they have teeth. It did not state the date of their last dental check. Medication is stored for each individual in a small locked cabinet in their bedroom. Boots supply the medication to the home using the monitored dosage system. Staff had signed Medication Administration Records (MAR) appropriately. The MAR cross-referenced with the blister pack indicating that medication had been given as prescribed. One service user is prescribed Midazolam – a ‘rescue’ medication for epilepsy. Staff had received training in how and when to administer it to the individual. A protocol signed by the Neurologist, Community Nurse and the Manager was in place stating when it should be administered. It was stored in the individual’s locked cabinet. There was a record of how much was received but this had not been recorded daily at handover of shifts to ensure that none of it was missing or being used inappropriately. Service users records sampled included a risk assessment for their medication. Their care plan referred to the medication they take and how and when staff are to administer it. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The 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 individual’s views are listened to and acted on. Arrangements are sufficient to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: A complaints procedure was in place and available for service users. This included all the relevant information on how to make a complaint and was produced using pictures so that it was easier to understand. There had been no complaints about the home in the last 12 months. Service users money is held securely in the home. Individuals finance records sampled cross-referenced with the amount that was in their purse or wallet. Receipts are kept of all purchases. Records showed that their money is spent on personal items and not on things that are the responsibility of the Provider. Each service user had a finance risk assessment to ensure that the risks of them being financially abused are minimised as much as possible. Staff had received training on adult protection and the prevention of abuse. Service users records sampled included guidelines on managing the behaviour of individuals. These included diverting the individual’s attention to another activity and using a calm approach so as to not make the person more agitated. Staff were observed talking to one of the service users who was upset as their plans to visit a friend had to be delayed. Staff explained to them Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 17 and ensured that they knew that they could visit later in the day with support from staff. They calmed down and were supported appropriately. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 18 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, 26, 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally arrangements ensure that service users live in a homely, comfortable and safe environment that meets their individual needs. EVIDENCE: The flats were generally well decorated and well maintained. The lounges in 225 showed signs of wear and tear and required redecoration. The laundry in flat 1 of 225 had been adapted so that service users can get in there and do their laundry or be supported to do so where appropriate. The dining room table in flat 1(225) was very worn. Staff said that the Manager had requested new dining furniture but had been told this will be provided for in next years budget. In the interim this table could be re-varnished or covered to make it look better. Staff said that new carpets had been ordered for the kitchen/dining room in flat 1 (227). Around the home there were framed pictures that service users had created in their art classes at college. Service users bedrooms were well decorated with good quality furniture and personalised with pictures of interest to the individual and photographs. Their bedrooms reflected individual’s cultural background, tastes and interests. One Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 19 service user had an astro-ceiling that lights up when it gets dark. One service user had a religious plaque and rosary beads above their bed. Staff said that the person regularly goes to Mass. Adapted bathing facilities and a walk-in shower is provided in each bathroom so that service users with mobility difficulties can access these. A snoozelen room has been built in the garden that all service users can use. A range of sensory and music equipment are provided to help service users to relax and the room is accessible to all the service users that live there. The large garden was well maintained and landscaped with gravel areas, grass and raised beds. There was garden furniture so that service users can spend time sitting in the garden. Tomatoes and vegetables were being grown in one part of the garden. Staff said that service users are encouraged to do gardening if they want to. At the side of 227on the ground floor there is a wellmaintained small garden with decking, grass and furniture is provided. There is a balcony on the first floor of 227 where service users can sit if they wish to. The home was clean and free from offensive odours. A contractor from a window cleaning company was cleaning the outside windows. In one of the car park bays there were some old pieces of furniture and bits of cardboard that needed to be disposed of. The Assistant Manager said that a skip is to be ordered to dispose of these. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 20 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, 34, 35, 36 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing, their support and development are variable, which could impact on the service provided. Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The Assistant Manager said that about 50 of the staff has completed NVQ level 2 in Care or above. Other staff have requested to do this training. Staff had received the Learning Disability Award Framework (LDAF) training. The Assistant Manager said that there were three vacancies for care staff in 225, two in 227 and one part-time waking night post. They said that they were trying to reduce the use of agency staff to try and maintain a consistent service. There were two agency staff on duty that afternoon. Staff said and rotas showed that this was the first time for a long time that agency staff were used. This was because extra staff were needed as staff were supporting a service user in hospital. Interviews for new staff were taking place on three days that week. Rotas showed that minimum staffing levels were met and bank staff not agency staff were used to cover the vacancies. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 21 One of the service users daily records sampled stated, “ Relaxed in my flat as we are short staffed.” Staff said that service users missed out on doing activities when they were short of staff. Previous reports had required that a review of staffing levels must take place. At the last inspection the Manager stated that the Operations Manager had completed a comprehensive review of staffing and service users needs that had been forwarded to the relevant placing authorities. A response from the respective authorities remained outstanding. At the last inspection the Manager advised that the provider was to address this with the different placing authorities. A requirement was made for the CSCI to be kept informed of developments. This remains outstanding. The Assistant Manager was not sure of the outcome of the review. Staff meeting minutes showed that there had only been three staff meetings in 2006. Staff said that one was booked three weeks before but was cancelled, as there were not enough staff available. There was also one booked for the following day but as the Manager and one of the Assistant Managers were involved in interviewing new staff this would also be cancelled. Three staff records were sampled. These included all the required recruitment records. Evidence that a satisfactory Criminal Records Bureau check had been received to ensure that suitable people are employed to work with the service users. Staff records sampled showed that staff had received training in fire safety, food hygiene, moving and handling, first aid, epilepsy, autism, adult protection, medication and infection control. One member of staffs records sampled showed that they required refresher training in moving and handling, food hygiene and first aid. The Dietician recommended that staff receive ‘In Proportion’ training on healthy eating and nutrition. Staff had not received this and it is required. Staff supervision records showed that out of twenty-three staff during 2006 one had no formal, recorded supervision sessions, ten had one, seven had two, three had three and two had four. All staff must have regular supervision sessions to discuss the support being given to the service users, how individuals are performing in their job role and identify any training and development needs. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that service users benefit from a well run home. Arrangements are not in place to ensure that service users are confident that their views underpin all self-monitoring, review and development by the home. Service users rights and best interests are not sufficiently safeguarded by the home’s record keeping practices. Generally the arrangements for health and safety ensure that the welfare of service users is promoted and protected. EVIDENCE: Staff were positive about the management style of the home. They said that the Manager listened to what they said and was concerned for the welfare of service users. They said that the Manager encourages staff to develop their skills and knowledge. Since the last inspection the Manager had been registered with the CSCI. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 23 A quality assurance system was not in place. A representative of the Provider visits the home monthly and makes a report of their visit as required under Regulation 26. Four service users records were sampled. Several of the night reports had not been completed in one of these and some daily records had not been completed in all records sampled. Where records had been completed they were well written and were non-judgemental about the individual’s behaviour. Fire records showed that staff test the fire equipment regularly to make sure it is working. An engineer regularly services the fire equipment. A fire risk assessment is in place that states how the risks of there being a fire are to be minimised as much as possible. In flat 2 (227) the fridge door handle was broken. In the fridge there was some food wrapped in foil. It was not labelled to state what it was or when it needed to be eaten. There was a bowl of fruit and jelly but this was not labelled as to when it was made and needs to be eaten by. Records showed that an engineer regularly services the hoists. An electrician tested the electrical wiring installation in January 2006 and stated that it was in a satisfactory condition. They required some minor work to be carried out and this was completed in March 2006. An electrician tested the electrical appliances in July 2006 to ensure that they are safe to use. A Corgi registered engineer tested the gas equipment in May 2006 and stated that it was in a satisfactory condition. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records showed that these tested between 4- to 43 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. A valid certificate of employers liability insurance was displayed in the home. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 24 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 x 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 1 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 1 x 2 2 x Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 25 Yes 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 Timescale for action 30/11/06 2. YA9 3. 4. YA19 YA20 5. 6. 7. 8. YA24 YA24 YA30 YA24 YA42 YA33 9. YA33 The Service User Guide must be updated with the information regarding change of Managers. 13(4) (a-c) All risk assessments must be regularly reviewed and updated where there are changes. 12 (1) (a) Advice from health professionals must be followed. 13 (2) Midazolam medication must be checked each day on handover of shifts. A record of this must be kept. 23 (2) (b, d) The lounges in 225 must be redecorated. 16 (2) (k) The rubbish in the car park must be disposed of. 16 (2) (j), 23 (2) The fridge door handle must c be replaced. 18(1)(a) The registered person must inform CSCI of the outcome of the reassessment of residents needs and the review of staffing levels. (Outstanding from previous inspection). 18 (1) (a) Vacant staffing posts must be recruited to. DS0000017174.V310381.R01.S.doc 31/10/06 07/09/06 11/09/06 28/02/07 30/09/06 30/09/06 15/10/06 31/10/06 Coleshill Road, 225-227 Version 5.2 Page 26 10. YA35 18(1)(c) 11. 12. YA19 YA35 YA36 12 (1) (a), 18 (1) (a, c) 18(2) 13. YA39 24 (1) (2) (3) 14. 15. YA41 YA42 17 (1) (a) (3) (a) 13 (4) (a, b, c) All staff must receive refresher /updates on mandatory training. (Outstanding from previous inspection). Staff must receive ‘In Proportion’ training. All staff must receive regular supervision meetings at least six sessions per year with records kept. (Outstanding from previous inspection) A quality assurance system must be in place that seeks the views of service users and where appropriate their representatives. All service users records must be completed. All food must be labelled with the date that it was made and when it should be eaten by. 31/10/06 31/01/07 30/11/06 31/12/06 07/09/06 07/09/06 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. 2. Refer to Standard YA24 YA33 Good Practice Recommendations The dining room table in flat 1 (225) should be revarnished or covered. Staff meetings should take place at least six times a year. Coleshill Road, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 27 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, 225-227 DS0000017174.V310381.R01.S.doc Version 5.2 Page 28 - 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. 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