Inspection on 11/07/07 for 58 Featherstone Road

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

58 Featherstone Road 18/07/06

58 Featherstone Road 14/02/06

58 Featherstone Road 04/08/05

58 Featherstone Road 09/03/05

58 Featherstone Road 07/10/04

58 Featherstone Road 12/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Featherstone Road, 58 Kings Heath Birmingham West Midlands B14 6BE Lead Inspector Jill Brown Key Unannounced Inspection 11th July 2007 09:00 Featherstone Road, 58 DS0000016715.V340385.R02.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 Featherstone Road, 58 DS0000016715.V340385.R02.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. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Featherstone Road, 58 Address Kings Heath Birmingham West Midlands B14 6BE 0121 444 6600 0121 443 5968 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Gareth Davies Care Home 4 Category(ies) of Learning disability (4), Sensory impairment (4) registration, with number of places Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 18th July 2006 Brief Description of the Service: Featherstone Road is a substantial detached home providing spacious accommodation and a specialist service for adults with sensory impairment and learning disabilities. The home is registered for four service users. The home is in a pleasant residential area of Kings Heath close to shops, churches, leisure facilities and Kings Heath Park. The home provides four single bedrooms, three on the first floor and one on the ground floor, and a small office / staff sleeping-in room. Two bedrooms have ensuite facilities and all are individualised to reflect service users personalities. There is a large bathroom upstairs and a toilet downstairs. The lounge is a good size and is comfortable and homely. The house has a large modern fitted kitchen and a dining room. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited the home on a day in July without prior notice. A key inspection was undertaken which looked at all of the key standards. The inspection took place over 8 hours. During the inspection a resident’s care, was case tracked. This case tracking involved observing the resident looking at all the records and information about them, looking at their medication and their room and how staff interacted with them and other residents. Information from an assessment a person needing the vacant place at the home was looked at. Conversations with the service users were limited due to their complex needs and limited verbal communication. We received two comment cards from relatives of residents of the home. The inspector also took into account information we had received from all sources about the home since the last inspection. Information was given to us in an Annual Quality Assurance Assessment (AQAA), which the home completed. The AQAA shows how the home rates their performance in the areas set out in this report. We received this AQAA before the inspection. We received three anonymous complaints about this service since the last inspection. The registered person has investigated these. The responses to these complaints have assured us that they have been investigated well. There have been attempts to resolve any issues although the concerns have not specific nor have they involved the care given to residents. What the service does well: SENSE have good assessment processes that ensure residents needs are fully explored so the home can meet them in a person centred way. The staff group is stable which is beneficial to service users. Having a stable staff group gives continuity of care. The home had a relaxed atmosphere and was clean and fresh. Staff actively promote contact with service users relatives. The majority of the staff group have completed NVQ training to level 2 or 3. The Acting Manager had a very good knowledge of what improvements could be made to the service and was continuing to make steps towards these. Complaints and concerns raised with SENSE are taken seriously and action taken to resolve issues raised. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Further work was needed to increase the variety of activities available. We recognise that for some residents this has to be planned in small steps. Whilst residents are having their health needs reviewed information about this stored in several places on the residents care file and this could lead to health checks not been carried out in a timely way. The records of meals provided to residents did not always show that residents had a healthy balanced diet. Improvements were needed on the medication administration to ensure that medication remained auditable and adequate safeguards were in place. There are plans to improve the environment and these need to be done to create a more stimulating environment for residents. A record needed to be kept of the hours staff worked as well as the proposed rota. Fire arrangements needed to be improved to ensure that all staff are well trained and practiced and checks are up to date. The home must ensure that evidence of a gas safety check are kept in the home. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and aspirations are assessed appropriately before an offer of placement is made. EVIDENCE: From previous inspections it was found that referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals. No new residents have been admitted since the last inspection. The home currently has one vacancy. Two people have had their needs partly assessed for this vacancy. The inspector looked at one of these assessments and found that information was collected from carers that had looked after the person most recently. The assessment information not only included information about the person’s health conditions and behaviour but also useful information in communication, what makes a good day and a bad day and the person’s routines. This information is vital to assist any new residents to settle in the home. The Acting Manager demonstrated that he was aware of the requirement that new residents are only admitted on the basis of a full assessment undertaken by people competent to do so. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are generally reflected in their individual plans. Risks are identified and plans put in place to minimise them. EVIDENCE: One resident’s care file was looked at in depth as well as a prospective new resident’s information. A care plan included assessment information and the basic information was added to in the last year. Care plans were extensive and covered all areas in the resident’s life including health conditions and behaviour, activity plans and routines but also in one file information about culture and customs. The plans had been recently updated with hand written amendments. A member of administrative staff was in the process of typing up these amended plans. The amendments to the care plans showed that staff had spent some time acknowledging changes in the resident. Care plans were becoming more realistic in what they can achieve. For example it had been acknowledged that Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 11 a resident that is supposed to wear spectacles will not tolerate them and this has been the case for a number of years. However it was found that residents were assisted to slowly accept new experiences even those that find change difficult. One resident had been assisted to attend a centre for an activity, the home and the centre were celebrating some success when they managed to get the resident out of the transport and into the centre to sit for a while. Care plans show the resident’s preferences for clothing, foods and what makes a good day or a bad day for them. This person centred approach helps staff provide care in a way the resident would wish. Communication was enhanced by the use of ‘objects of reference’ that the resident associates with an activity such as a towel for bath time. The acting manager was starting to build boxes of these objects for resident’s to communicate to staff their needs. Although the residents are not able to formally input into their plans, the reviews assist with what is and is not working. Communication is seen as an important part of the care of residents by the acting manager and the objects of reference are to become more prominent in all areas of the building. The Annual Quality Assurance Assessment (AQAA) showed that there were difficulties in getting and maintaining advocates for each resident however comment cards from relatives showed that they are consulted. A comment card from one resident’s family said ‘We are always kept up to date on issues affecting (the resident’s name) and have opportunities to attend briefing meetings twice yearly,’ another comment card stated that they were regularly in contact with the staff at the home. Each resident has a core team of staff, who meet monthly, to monitor the care plan, progress on achievements, goals, health care and to action any points. Minutes of these core meetings were available in the file sampled for May and June said that the resident was ‘happy to get out of the bus at the Lickey hills’ … ‘Went to Waseley hills and Coriander Close,’ ‘has new clothes and shoes’ ‘been to Torquay for a holiday but didn’t like getting out of the bus needs two staff when in the Community.’ The risk assessments for residents have been reorganised and now more accessible being ordered for each resident’s name. A risk assessment for one particular resident was not looked at, at this inspection. The behaviour with stones remains part of the resident’s behaviour and this must be re looked at when the new resident arrives for potential risks. The AQAA provided by the home stated that risk assessments had been updated and were in separate files for each resident. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Activities need to continue to develop to ensure that residents have more realistic opportunities. The food menu is not ensuring that people living in the home experience a healthy lifestyle. EVIDENCE: Records showed that residents engage in activities that are meaningful to them and there were efforts made to broaden their experience. Assessments showed what tasks a resident could do for themselves and during the inspection a resident was seen undertaking one of these specific tasks. Care records showed that a resident case tracked had opportunities to go out into the community and to centres for activities. The acting manager was keen to keep increasing the number of activities residents could undertake as part of a person centred approach. On the day of the inspection one resident had gone to visit with their relatives supported by 2 staff. One resident’s records showed Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 13 that they went for rambles went out for meals had massage and foot spa sessions. There was evidence that resident’s are fully supported by staff to maintain contact with relatives. It is an area of good practice that SENSE employs a Family Liaison Officer. Regular newsletters are sent out to relatives. Additionally, a family weekend is arranged annually at a local hotel where relatives can meet with SENSE representatives and other relatives. Relatives commented ‘Carers send birthday cards to family’ on behalf of the resident. ‘They bring (residents name) down to see us which is very rewarding for us all. We visit every month. The AQAA and the discussion with the acting manager showed that he was aware of the needs of relatives. He was looking at plans to improve the garden and within the building so resident’s can have a comfortable space and time with their relatives. Aids were available to assist residents. Flashing doorbells enabled resident’s to be aware that staff needed to enter their rooms. A resident had their own toilet facilities to ensure that they could remain independent. A resident had been assessed for improved bathing facilities. The food prepared could be improved. The care staff prepare meals for residents. The menus provided were not always what resident’s had to eat. Food records showed that residents had enough to eat but further development of menus was needed to ensure that resident’s have a diet that was healthy. Within a week one resident had two days where they had two main meals. Records did not show that residents had the benefit of five portions of fruit or vegetables a day. Fruit was always available in the lounges. Resident’s have meals out as well as food within the home. The reports of monthly visits on behalf of the provider had found that there were too many frozen foods used. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed in the consistency of records and the ease in which they can be accessed to ensure residents health needs are appropriately monitored. The process of medication administration needs further checks to ensure that residents wellbeing is safeguarded. EVIDENCE: Care plans contain detailed information on the support needs of resident’s, and take into account gender care needs. Resident’s were well dressed appropriately to their age. Care plans contained information about resident’s preferred clothing and for the resident case tracked the clothing worn on the day of the inspection matched these preferences. The staff and manager on duty assisted residents appropriately and all these interactions were calm and friendly. The home has both female and male resident’s and the staff group is also gender mixed. The home has two staff from an African Caribbean background the rest of the staff being white Uk and this reflected the cultural background of the residents. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 15 Resident’s have health action plans in place. These are not easy to up date and information not always easy to retrieve; this was noted in the homes AQAA. From the information available we were able to see that resident’s health was checked routinely. Residents have specialist hearing and vision checks, as well as checks for any other health condition identified. Resident’s have the benefit of routine health checks such as flu vaccinations, dental and chiropody appointments. Medication records and stored medication were looked at the following found. There was a photograph each resident with the medication administration records (MAR). This is good practice because it ensures that new staff have a further safety measure. There are clear medication procedures in place. The information inserts from medications are kept so that staff can check if they are concerned about a resident. A copy of the current prescription was not with the MAR, which means staff were not checking that the medication received is as last prescribed. Medication procedures that were not relevant to the particular resident were with their medication administration charts such as crushing of tablets and this may lead to wrong administration. The medication administration record was being transcribed to other records; the transcribing did not always include the amounts brought into the home and the start date and this made auditing of some medication difficult. In this home a count down of ‘as required medication’ and an indication of when liquid medication is started may assist the home in its audits. Staff have 6 monthly checks on their competence to give medication and evidence of these were found in staff records. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints are satisfactory to ensure that residents views are listened to and acted on. Arrangements are sufficient to ensure that residents are protected from abuse. EVIDENCE: The homes complaint procedure includes information on the role of the CSCI in investigating complaints and is available in a picture format and CD Rom. Some of the resident’s due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. Complaints have been raised anonymously; the registered person has investigated these. The responses to these complaints have assured us that they have been investigated well. There have been attempts to resolve any issues although the concerns have not specific nor have they involved the care given to residents. The acting manager and area manager were open about concerns and complaints and described incidences when perhaps the homes performance had not lived up to a relative’s expectations. They spent some discussing what they hope to do in the future to increase relatives’ satisfaction with the Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 17 service. Two comment cards we received from relatives showed that they were satisfied with the service. Copies of the Birmingham Multi Agency Adult Protection guidelines and the homes adult protection flowchart were observed to be readily available to staff. The home has a written prevention of abuse policy that is robust. Records show that staff have received training in adult protection. There have been no adult protection issues since the last inspection. Records of residents’ money were checked and found that the money held in the home were correct with the record. Receipts were produced for any spending. One staff signature was in place for transactions and it is better practice to have 2. Only money spent was recorded, however staff took larger amounts of money out with them and brought change back. A more accurate record would show this so the record always matches the money held. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment is pleasant and homely but is not as stimulating and interesting as it could be. EVIDENCE: A tour of the building was undertaken. The date of the inspection coincided with decorative work being done and the acting manager going out to purchase furniture. There appeared to be many plans to update the facilities, these had yet to be completed. The garden was neat and tidy with baskets of flowers on display attached to new fences. The manager stated that they have plans for a summerhouse and wants to landscape the garden with some aromatic plants; this is also recorded in the staff meeting minutes. The summerhouse was hoped to multi functional so apart from a place where relatives and residents could meet it would provide an activity base. Resident’s are currently growing potatoes tomatoes and strawberries. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 19 The doorframes were being painted black and corridors yellow to increase the visibility of the doorways for people with sight loss. Residents’ rooms were individual style and reflected their behaviours and things they enjoyed. For example one room had lots of storage space and belongings others less so. One residents room had luminescent stars and animals painted on the ceiling. Another resident had a massage chair in their room. The toilet, bathing and showering facilities were good and met the needs of residents currently. An occupational therapist had assessed the need of one resident for differing facilities and funding for this was being investigated. The home was clean and fresh at the time of the inspection. There are adequate laundry facilities to meet the needs of residents. The kitchen was clean however a freezer needed defrosting and meat in the freezer needed the date that meat was frozen recorded. Requirements of the previous inspection had been acted upon. The plans for improvement of the home, the building of a summerhouse and the development of a more communication based environment could ensure a more stimulating place for residents. Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing and their support and development are generally sufficient to ensure that an effective staff team supports residents and meets their individual needs. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: Resident’s appeared happy with the their interactions with staff. Resident’s were seen to approach members of staff if they wanted something and staff used different methods to find out what resident’s wanted. Resident’s had time spent with them even if they were resting and not asking for attention. Eighty five percent of the permanent care staff have a National Vocational Qualification in care level 2 or above. The home states that it uses agency staff to cover staff sickness, annual leave and it was noted two permanent staff assisted a resident to visit their relatives. Although the AQAA stated that the Agency staff used do not have an NVQ2 this was not true on the day with the agency staff member being well qualified. One comment card stated ‘more permanent staff less agency’ would be an improvement. Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 21 Proposed rotas showed that there were two staff on duty to meet the needs of the three residents. One resident had extra funding for one to one time twice a week. There is one night staff on duty and a sleep-in member of staff. The hours staff work are signed for and staff compliance on this was variable. Discussion with the acting manager and area manager indicated a staffing review would take place prior to a new resident being admitted to the home. There had been no new staff recruited at the home however staff files sampled showed contained all the information as required and included satisfactory evidence that a CRB check had been obtained so that resident’s are protected by a robust recruitment procedure. The staff training matrix supplied showed SENSE has a rolling programme of training for staff. The staff files showed that staff had more training than the matrix suggested. All staff have now completed epilepsy and bereavement awareness training. Fire training was not current for the majority of staff Featherstone Road, 58 DS0000016715.V340385.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there has been improvements in many areas some monitoring of processes is needed to ensure that all health and safety checks are done and evidence is available. EVIDENCE: The management of this home has undergone many changes in personnel. The current manager of the home is currently off work and an acting manager is in place that has transferred from another SENSE home. He has undergone the registration process with us and has been successful in becoming a registered manager. He has to complete the National Vocational Qualification level 4 and the Registered Managers Award which are the recognised training for managers. SENSE has advertised for a permanent manager and until this Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 23 happens then it is difficult for staff to believe that there is clear vision for the home. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are also carried out periodically to include health and safety, financial, environment and outcomes for residents. SENSE as an organisation has also developed a staff development plan that covers induction and staff training. There was evidence of staff meetings and that these meetings looked at the service provided and tried to improve this for residents. In respect of fire safety the home had procedures that included what to do if residents refuse to leave. The fire risk assessment was due for renewal however the home manager was aware of the change of the fire regulations and was building this into the review. The fire alarm weekly tests had not been recorded weekly for about a month. The records of fire drills held could be improved by adding any learning points. Not all staff have had routine fire training in a timely way although training is planned for August this year. There were copies of all appropriate health and safety certificates except for the Gas Landlords certificate. There was evidence of the visit by their maintenance company to undertake this task however a copy must be in place in the home for inspection. This was undertaken before the report was published. Featherstone Road, 58 DS0000016715.V340385.R02.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 X 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 3 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 2 14 X 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 2 X Featherstone Road, 58 DS0000016715.V340385.R02.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 YA12 YA13 Regulation 16(2)(m,n) Requirement Timescale for action 30/09/07 2 YA17 12(1 a) 16(2 i) 3 YA19 12(1)(a) Sch 3 (3) (m) 13(2) 4 YA20 Review the arrangements for activity opportunities for residents to ensure they are realistic, varied and activities undertaken are in line with activity plans. Partly met outstanding since 30/09/06 Menu planning must be 30/09/07 reviewed to ensure residents receive a balanced, varied, culturally appropriate and healthy diet. Outstanding since 30/09/06 Ensure the recording of health 30/09/07 care is improved to enable healthcare of residents to be satisfactorily tracked. A safe system of administering 30/08/07 medication must be put in place that is audited for compliance to include: Removal of procedures in the resident’s medication folder that do not apply to the resident. The accurate transcribing of the amount of medication received Featherstone Road, 58 DS0000016715.V340385.R02.S.doc Version 5.2 Page 26 into the home and date received on to the medication records held. Keeping a copy of the latest script so that medication supplied can be checked against it. Noting when bottles of liquid medication are opened so that an audit of liquid medication can take place. Arrangements fire safety must be maintained:Staff must have timely training. Fire alarm tests must be maintained. A record of outcomes of fire drills should be maintained and all staff should have the benefit of a fire drill every 6 months. Evidence of a gas safety certificate must be kept at the home. 5 YA42 23(4) 30/08/07 6 YA42 23(2)(b)(c) 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Risk assessments. It would be beneficial if evidence of evaluation of the assessments was recorded on the review sheet in addition to the current system of staff just signing to say they had been reviewed. Previous recommendation not assessed on this occasion. Records of residents’ money should reflect the money held at all times. The records of transactions should have two signatures wherever possible. There must be an accurate record kept of the rota staff have worked as well as the proposed rota. DS0000016715.V340385.R02.S.doc Version 5.2 Page 27 2 3 YA23 YA33 Featherstone Road, 58 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Featherstone Road, 58 DS0000016715.V340385.R02.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. 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