Inspection on 07/04/09 for Elmdon House

This inspection was carried out on 7th April 2009.

CQC 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 CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 28/06/2009.

Key inspection report CARE HOME ADULTS 18-65 Elmdon House 190 Elmdon Lane Marston Green Birmingham West Midlands B37 7EB Lead Inspector Donna Ahern Key Unannounced Inspection 7th April 2009 10:40 Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmdon House Address 190 Elmdon Lane Marston Green Birmingham West Midlands B37 7EB 07826 528 0673 0121 708 0673 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) Midway Care Ltd Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either To service users within the following category 2. Learning Disability (LD) 6 The maximum number of service users who can be accommodated is: 6. New registration. Date of last inspection Brief Description of the Service: Elmdon House is a large detached house and provides twenty-four hour care and support for six people with Learning Disabilities. Six people were living at the Home at the time of the Inspection. The Home is situated in Marston Green. It is near to the centre of Marston Green village where there are a variety of shops, transport links and leisure facilities. There is a large lounge with double doors opening into the dining room. A domestic style kitchen, separate laundry and office. There are six single bedrooms, each one with an en-suite bathroom. Five have a shower facility and one bedroom has an ensuite bathroom. Three of the bedrooms are on the ground floor and are accessible to a person with limited mobility. All other bedrooms are on the first floor. A stair lift provides access to the first floor. To the rear of the Home there is a large garden with lawned area and patio, and to the front of the Home there is off street parking. Plans are underway to provide a sensory room for people and a staff sleep in facility. Building work should commence in the next few months. The statement of purpose seen stated that the current fee range for living at the Home is £1473.23 per week. The fee does not include personal clothing toiletries, electrical items and meals eaten outside of the Home above the Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 5 allowance allowed and activities not covered in the contact. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is ONE star. This means the people who use this service experience ADEQUATE quality outcomes. One inspector carried out this inspection over one day; the home did not know we were going to visit. This was the homes first key inspection. The focus of inspections we, the commission, undertake 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 provision that need further development. Six people were living at the home. All people have a learning disability. We case tracked three peoples care 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. Some of the people who live at the home were not able to tell us their views because of their communication needs. Time was spent observing care practices, interaction and support from staff. The manager, service manager and three staff on duty were spoken to. We looked around some parts of the Home to make sure it was warm, clean and comfortable. We looked at a sample of care, staff and health and safety records. We were sent an Annual Quality Assurance Assessment (AQAA) by the home. This tells us about what the home think they are doing well and where they need to improve. It also gives us some numerical information about staff and people living at the home. We also looked at notifications received from the home. These are reports about things that have happened in the home that the Home must tell us about. We sent out 6 surveys to people living in the Home to seek their views and opinions, 6 to staff and 6 to professionals. We received 5 completed surveys from people living at Elmdon House and 2 from staff. Comments received are contained in the main body of the report. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 8 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Elmdon House DS0000072882.V374943.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 Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People using the service experience Good quality outcomes. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their relatives have the information they need to know so they could make an informed choice about whether they wanted to live at the home. EVIDENCE: We were told that people all moved into Elmdon House over two days in November 2008. Five people came from a home that was closing and one person moved from a respite service. The previous manager had completed pre assessments in September 2008 to determine if Elmdon House could meet peoples care needs. We asked about how the move was planned for people and we were informed that there was not an opportunity for people to have a phased transfer due to the circumstances at the Home they were moving from. However people did visit the Home before they moved in. We saw assessments completed by Social Services, which gave some information about how peoples needs should be met. People told us Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 11 I like it here I want to stay here I don’t want to move The service user guide and statement of purpose tell people what they can expect from the home and had been written in a style that is easier for the people living there to understand. It included details of fees so that people know what they are paying for. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and risk assessments have most of the information that staff need to meet peoples assessed needs and protect them from the risk of harm. EVIDENCE: We looked at three care plans. Care plans explain what each person needs are and the care and support they require to make sure these needs are met. We were told the care plans had been developed by talking and getting to know individuals, using information and assessments completed by social services. Staff told us that information about peoples needs from their previous home was limited. We found that the files looked at gave information about how staff should support the person in order to meet their individual needs in relation to personal care, communication, health care and social activities. The plans also Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 13 gave information about peoples likes and dislikes. We were told that the care plans were still very much being developed as people settled in their new Home and staff became more familiar with how people want to be supported. One of the people had said and it was recorded in their care plan that they wanted to return to church to practice their faith. The person had been supported to achieve this but this information had not been recorded. We saw other examples where people had identified things that they wanted to achieve such as walk to the shop go out in the community more it was unclear if these needs had been met. We recommended that where goals for people had been set and achieved this should be recorded so progress can be monitored and needs planned for. We spoke to three members and we also observed people being supported by staff. The staff demonstrated knowledge of peoples individual needs which was consistent with the information on peoples file. This indicates that staff know how to provide care and support to people so their needs are understood. We saw risk assessments for showering, falls, use of car, laundry, use of stair lift. These ensure that people could take responsible risks according to their individual needs. Staff spoken with also knew what they must do so people are not put at risk of harm. We saw people receiving good support from staff. People were seen making different choices about how they spent their time. Some people went out to do the house food shopping and some people went out for a walk. One of the people declined the opportunity to go out and this was respected. People were seen freely accessing their bedrooms and different areas of the Home. We saw from care records and talking to people and staff that people are encouraged to make choices and decisions about their daily lives. Staff said that when some of the people first came to live at the Home they had to be encouraged to make decisions and they were not use to freely accessing areas such as the kitchen to make a drink or snack. People had been supported to take part in house meetings however minutes of the meetings showed that although one had taken place recently these, were infrequent. The manager said that these would now take place monthly so that people have an opportunity to talk about how the Home is run. The AQAA informed us that key worker sessions take place once a month with peoples involvement and family, friends and social workers are also invited to these meetings. People will have an opportunity to raise concerns or say what is working and where they require more or less support. The key worker will record this and at the same time update support plans as well as risk assessment, and goal sheets. We saw that there are systems in place to review peoples care such as monthly summaries, key workers reports and reviews. However these had not yet been fully implemented. When they are Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 14 they should ensure that the support people require and how they want this to be given will be kept up to date so their needs are met. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 15 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): 12,13,15,16 and 17 This is what people staying in this care home experience: People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the Home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs and interests. EVIDENCE: We looked at care plans and daily records to establish that people are leading meaningful lifestyles and taking part in activities that they enjoy. We also spoke to three staff members and observed care and support on the day. We were told before people moved to Elmdon House that most attended structured day centres but people no longer attend these as the centres are either closed or are closing. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 16 Care plans gave some information about what people like to do recorded under Things most important to me and likes and dislikes. We also saw pictorial calendars in use so people know what they are doing each day. Most people attend colleges for part of the week. On the days that people don’t go to college people are supported to go to places of interest and out shopping or to enjoy home based activities. One person said, I like to go to the pub for a meal. We were told that there are plans in place to have a sensory room at the Home and building work on this should take place in the near future. We were told that opportunities for people are still being explored. Staff told us that some people are refusing activities and the reasons why need to be explored further so their individual needs can be met. We recommended that activities be evaluated to establish if the person is enjoying and gaining from the activity so that this information can be used for future planning. People moved freely around their home accessing their bedroom or communal lounge, kitchen or dining room. One of the people chose to spend some time out in the garden. Bedroom doors are lockable. We were told that only one of the people has requested to have a key to their bedroom. People told us about family and friends who are important to them. One person spoke about his brother and one person showed us photographs of family members that were really important to them. Another person received an Easter present from their sister and they received really good support from staff to open the present and read the card attached. Care files had details of people important to me . So people receive support to maintain relationships with people that are important to them. We saw that people are encouraged and supported to tidy their bedroom, do some cleaning tasks and do their laundry so they can maintain and develop life skills and promote their independence. We were told that people are involved in the planning of menus and participate in food shopping and some food preparation. We saw that people went food shopping on the day of our visit. We saw a range of tinned, frozen and fresh food. Records of food served indicated that a variety of nutritious meals that reflect cultural and taste preferences were available. People said I can have a drink when I want one. We saw people helping themselves to a drink or being supported to have one. We saw people having snacks including fresh fruit between meals. At meal times we saw that staff sat and chatted to people and observed that people were eating their meal safely. Staff told us in the completed and returned surveys More outings and activities should be arranged for people. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience Adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems in place do not always ensure that people health care needs are properly monitored which may lead to health care needs not being met. EVIDENCE: Care plans that we looked at had good detail about how to meet peoples personal care needs these were described under This is my day. This gave detail about how much support people required from staff and also detailed how people should be encouraged to do as much for themselves in order to maintain their independence. We recommended that the support people require from waking night staff is risk assessed and used to inform night time guidelines so people get the support they need to be safe whilst not disturbing their privacy. We were told that some people arrived at Elmdon with limited personal clothing and people are now being supported to go shopping for clothes and personal items that they need. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 18 Health action Plans are in place and are still under development so that peoples individual health care needs are monitored and support needed provided. We saw that referrals had been made to different professionals such as speech and language, psychology and chiropody so that specific health care needs are met. We looked at the log of health care appointments and saw that for two of the three people we case tracked the outcome and follow up of recent medical appointments and interventions had not been recorded on the health log or in any other records kept in the home. Incomplete records may lead to peoples health care needs not being met and could be detrimental to peoples well being. We were told that the speech and language therapist is working on guidelines for one person who needs support when eating meals. There was information on the persons care plan about how to prepare their food. We saw that during mealtimes staff sat with the person and gave them the support they need. A risk assessment must be in place so that any known risk are clearly stated and staff are clear about what they need to do to minimise any risks. We saw that some equipment is available to promote peoples independence including ramps, stair lift and hand rails. We saw that staff have had training on sensory deprivation and vision impairment and training is planned for moving and handing and falls awareness so they can promote peoples independence and know how to provide a safe environment. Staff spoke positively about the recent dementia training they had completed and said how this will really help them with supporting people. We saw that information about specific health conditions had been researched and were available for staff to read so they have a greater understanding of peoples health care needs. We were told that staff have just started to monitor peoples weight, which can be an important indicator of other health care concerns. Advice is also being sought about how people can be supported with healthy eating to promote good health and well being. We looked at the arrangements in place for medication management. Staff informed us and training records seen confirmed that staff responsible for medication management had completed training. Medication is stored in a separate locked wall mounted medication cabinet in the dining area. The cupboard was found to be clean, tidy and well ordered. The medication administration Records (MAR) looked at was signed indicating medication had been given as required. Copies of prescriptions are retained so that staff can check the right medication has been received from the chemist. There were no controlled drugs at the Home. None of the people self-administered their medication. It was recommended that peoples consent to medication is obtained and recorded on their care plan. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):22 and 23 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to listen to and respond to complaints and to protect people from the risk of harm. EVIDENCE: All of the people living there had a copy of the complaints procedure, which is available in an easy read format so it is more meaningful for the people who live at Elmdon House. The commission has received no complaints about this Home and no complaints have been made directly to the service. People told us I can talk to staff . In the surveys we sent out we asked people if they knew how to make a complaint. They told us Tell the manager Go to the office tell the manager Tell X in the office Speak to X, X and X (all staff members names) Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 20 Staff we spoke to demonstrated a general understanding of their duty to safeguard people and how to report concerns on to senior managers. We spoke to staff and looked at training records to determine that training in safeguarding vulnerable adults had been provided. We saw that further training is scheduled for June for staff who havent yet completed it. Safeguarding procedures and a whistle blowing policy was available for staff to refer to. This ensures that staff have guidelines to follow in the event of an allegation being made. We saw inventories of peoples belongings on their case files. This ensures that peoples personal items are protected. We saw well-organised records for the management of peoples personal finances. Details of peoples personal expenditure and running balance were seen. We did not examine these in detail. It was recommended that risk assessments were put in place for the safe handling of peoples money the manager dealt with this recommendation immediately. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 28 and 30 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean, safe and comfortable home, which promotes their well being and meets their individual needs. EVIDENCE: The Home is suitable for its intended purpose of providing domestic style accommodation and care in an ordinary environment. The Home looks no different to others in the area and is not distinguishable as a care home. The building has been refurbished to a high standard and provides a homely living environment that is fit for purpose. People are now being supported to personalise their own rooms. All bedrooms offer single occupancy and have an ensuite consisting off a toilet, five have showers and one has a bath. At the Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 22 time of registering with us it was highlighted in the registration report that there is no separate communal bathroom within the home thereby offering a choice of bath or shower to five of the six occupants. The facilities remain as at the point of registration and it is recommended that consideration be given to ways of how this may be resolved in the future if needed. It was also raised in the registration report that the provider was to seek planning permission to construct a staff sleep in room. The short-term arrangements were that the staff office is utilised for this purpose. At the time of this visit planning permission has been given and work is due to commence soon to construct the additional room. There is a spacious pleasant and secure rear garden for all people living at the home to use. We were told that there are plans to create a sensory garden for people to enjoy. Three bedrooms are on the ground floor and three on the first floor. Access to the first floor for people with limited mobility is provided by a stair lift. There is a spacious lounge with comfortable seating and a large screen television and is a very pleasant room for people to relax in. Double doors lead to a spacious dining area. The kitchen was clean and well equipped with adequate space to store fresh, frozen, dried and tinned food. All areas of the home were clean and hygienic indicating good cleaning routines. There is a separate laundry room, which was clean and organised. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s):32, 33, 34, 35 and 36 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who have a good understanding of peoples individual needs. The recruitment procedures in place protect people from the risk of harm. EVIDENCE: We watched the way that people interacted with staff on duty, which indicated that good relationships exist between people living there and the staff supporting them. We looked at the staffing rota for the week of the visit and the previous two weeks. These showed that there is generally three staff on duty to care for the people living there during the day. Frequently the third person does a middle shift so staffing levels falls to two on shift after 5 or 6pm. Some of the people require 1:1 support to go out. The current staffing arrangements on certain days restricts peoples opportunity to go out in the evening. The staffing arrangements must be kept under review so that there is adequate staff on Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 24 duty at all times to meet peoples assessed needs. At night one staff member is on duty and one staff member sleeps in and is available to give support if needed. We could see from the rota that there is a senior person on most shifts this should ensure that staff are supported in their role each day. We spoke to three staff during this visit they demonstrated that they had a good understanding of peoples individual needs and were enthusiastic about their work and keen to learn and develop their skills. Staff told us they had an induction to the work place when they first started. The manager told us that the induction package has just been revised to the skills for care. We did not look at this during this visit. We spoke to staff about the training they had received and they said that they had completed training in mandatory areas including safeguarding, medication, health and safety, We looked at the staff training matrix, which confirmed mandatory training had taken place and training is also scheduled to take place in April on fire safety, Manual handling and infection control. Adult protection training is scheduled in June for staff who haven’t yet completed it. Training specific to meeting peoples individual needs has also taken place including dementia, sensory deprivation and vision awareness. Training on autism awareness and mental capacity act is in the process of being arranged. This should ensure that staff have the up to date knowledge and skills required to meet peoples individual needs. We looked at staff recruitment records for three staff members. The Home used a staffing agency when it first opened to recruit suitable staff. Criminal Records Bureau checks (CRB) had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the Home with them. We were told that the manager is now auditing and reviewing all staff files so they comply with the Homes own recruitment procedure and staff are required to complete new paper work to achieve this. Staff told us that supervision has been infrequent due to manager changes but a new supervision structure is now in place. A lot of the staff employed are new to care so it is important they get the support and opportunity to reflect on their practice and consider their individual training and learning needs. Regular staff meetings take place, which provide an opportunity for staff to discuss good practice and development issues. Staff told us in the completed and returned surveys The training courses I have been on have been very helpful especially y the course on dementia which I found really interesting. Elmdon House DS0000072882.V374943.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 43 People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements in place generally promote the health, safety and well being of people. EVIDENCE: The home has experienced a number of management changes since registration in November 2008. The new manager was a week in post when we did this inspection and had worked at the Home through a recruitment agency since January 2009. She was very open and welcoming to the inspection process. The Homes service manager, who has managed the Home for periods when there has been no manager, was also available throughout the visit. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 26 Staff spoke very highly of both the manager and service manager and said they were approachable supportive and would get things done. We looked at the record of visits by the registered provider and saw that the last visit and report was completed in November 2008. It is concerning that these visits were not completed through a period when the Home had just opened with a new staff team and through a period of management changes. These visits must be completed monthly so the provider can ensure that the Home is run in the best interest of the people living there. We have highlighted earlier in this report that staffing levels must be kept under review. Some work to risk assessments was also required so that people are supported to be safe. There are quality assurance systems in place including an auditing system. However as the Home is fairly new these are still in the process of being developed. We were told that surveys would be sent to people living in the Home, their relatives and other professionals to seek their views on how the Home is being run. We looked at some health and safety records including Fire records and water temperatures checks all are checked and serviced regularly so that peoples health and safety is being promoted. We recommended that fire risk assessments are completed for each person living in the Home and should include any specific requirements such as hearing, vision or mobility difficulties that may impact on individuals responding to the fire alarm. If any advice is needed when completing the risk assessments this should be sought from West Midland Fire service. There are systems in place for the recording and monitoring of accidents. Staff spoken with and records looked at confirmed that staff have completed training on health and safety, first Aid and food hygiene. Fire training and manual handling was scheduled for April. This should ensure that a safe environment is provided for people. The AQAA had been completed to a satisfactory standard. It made the following comments about the conduct of the home. There are effective management systems, administration systems and record keeping. Elmdon House DS0000072882.V374943.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 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 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 2 X Version 5.2 Page 28 Elmdon House DS0000072882.V374943.R01.S.doc 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 2 Standard YA19 YA39 Regulation 12 (1) a, 26 Requirement Arrangements must be in place to ensure peoples health care needs are met. The owner must carry out monthly visits to the Home to make sure it is being run in the best interest of the people living there. Timescale for action 25/05/09 30/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA6 YA8 YA13 YA18 YA18 Good Practice Recommendations Further develop the care planning systems so peoples needs are well planned for. Regular house meetings should take place so people have the opportunity to make decisions about their home. Arrangements should be in place to review and evaluate activities so people are supported to do the things they like and enjoy. Risk assessment should be completed for people who are at risk of choking so staff have the information they need to keep people safe. Risk assessments for the support people need at night DS0000072882.V374943.R01.S.doc Version 5.2 Page 29 Elmdon House 6 7 8 9 10 11 YA19 YA33 YA36 YA37 YA39 YA42 should be completed so people receive the care they need. Peoples consent to medication should be obtained and recorded on their care plan. Staffing levels should be kept under review to ensure that there is enough staff on duty at all times to meet peoples needs. Arrangements must be in place to ensure staff receive supervision so staff get the support they need to do their job and meet peoples needs. An application should be made to CQC register a manager so people benefit from a consistent management approach. Quality monitoring system should include the views of people living at the home. Individual risk assessments for supporting people in the event of a fire should be in place so people receive the support they need to move safely. Elmdon House DS0000072882.V374943.R01.S.doc Version 5.2 Page 30 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Elmdon House DS0000072882.V374943.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!