Inspection on 14/02/07 for Ferndale Crescent, 10

This inspection was carried out on 14th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferndale Crescent, 10 30/06/09

Ferndale Crescent, 10 03/07/08

Ferndale Crescent, 10 10/11/05

Ferndale Crescent, 10 04/05/05

Ferndale Crescent, 10 23/09/04

Ferndale Crescent, 10 26/04/04

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 Ferndale Crescent, 10 Moseley Birmingham West Midlands B12 0HF Lead Inspector Kerry Coulter Unannounced Inspection 14 February 2007 10:00 th Ferndale Crescent, 10 DS0000016880.V322529.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 Ferndale Crescent, 10 DS0000016880.V322529.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. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferndale Crescent, 10 Address Moseley Birmingham West Midlands B12 0HF 0121 772 1885 0121 766 6856 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) erikal@trident-ha.org.uk Trident Housing Association Ms Maria Bulloch Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Ferndale Crescent, 10 DS0000016880.V322529.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 10th November 2005 Brief Description of the Service: 10 Ferndale Crescent is located in a residential area of Highgate on the outskirts of the city centre. Therefore the city centre is easily accessed by public transport. The home is registered to provide support to eight adults who have a physical and learning disability on a permanent basis. The home is owned and managed by Trident Housing Association. At the time of this inspection there were six residents living in the home. The home caters for adults of mixed gender. All bedrooms are single and have an ensuite facility. There are six bedrooms on the ground floor and two on the first floor, which can be accessed by a chairlift if required. Three of the bedrooms have an overhead hoist. The communal areas comprise of an open plan lounge and dining room, kitchen and sensory room on the ground floor. The laundry is situated on the first floor. The home is staffed 24 hours a day and at night there is one waking night staff and one member of staff sleeping -in. The pre –inspection questionnaire stated that the fees charged range from £905 to £1122.13. The latest CSCI inspection report is available in the home for visitors if they wish to read it. Ferndale Crescent, 10 DS0000016880.V322529.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, a pre – inspection questionnaire completed by the Manager, sample menus and rotas and comment forms completed by service users and their relatives. One inspector carried out the unannounced fieldwork visit over six 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 all the 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. The Manager was not on duty at the time of the visit but was later spoken with by telephone. What the service does well: Service users who may want to come to live at the home have the information they need so they can make a choice about whether or not they want to live there. There was a friendly atmosphere about the home and service users seem happy. One said ‘staff always listen, I would not want to live anywhere else’. Staff support service users to go to the places they want to go to. Staff support service users to go on holiday and out for day trips. They talk about these at service users meetings so they get to say where they want to go. The Tenant Participation Officer who is employed by Trident chairs the meetings. The diverse needs of service users is recognised in the activities offered, individual’s culture is valued and there are opportunities to share other people’s culture. Service users have a choice of what they eat and drink and if they want a big meal or just a snack. Staff spend time talking to service users and finding out what they like and don’t like and what things they would like to do. The health and safety of service users and staff is considered to be important. Regular checks on equipment are done to make sure they are working and safe to use. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The premises needs to be more accessible to service users who use a wheelchair. The kitchen and laundry must be accessible so that they have a chance to develop their skills in independence. One bedroom and en suite had an offensive smell. This needs too be resolved so that they are nice rooms for the service user to spend time in. Staff need appropriate challenging behaviour training earlier in their employment to ensure they have the right skills and knowledge to manage behaviour. Ferndale Crescent, 10 DS0000016880.V322529.R01.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. Ferndale Crescent, 10 DS0000016880.V322529.R01.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 Ferndale Crescent, 10 DS0000016880.V322529.R01.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): 1,2,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice as to whether or not they want to live there. Arrangements are in place so that prospective service users individual aspirations and needs can be assessed. Service users have a written statement so that they are aware of the terms and conditions of their stay at the home. EVIDENCE: The service user guide and statement of purpose of the home had recently been updated. They included all the required and relevant information. The service users guide to the home was produced using pictures so making it easier to understand. Staff said it was planned for this to be available in an audio version in the near future. Service users said they had information about the home before they moved in. The admission procedure stated that the home would accept referrals for individuals that have been assessed by a social worker to ensure they meet the criteria for living at the home. The procedure includes trial visits to the home to include an overnight stay. It was good that the procedure was available in an easy read format that includes pictures so making it easier for service users to understand. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 10 One service user had been admitted to the home since the last inspection. Records and discussion with staff show that assessments had been completed prior to moving in to establish that the home could meet their needs. Each service user had a licence agreement with Trident. This stated the terms and conditions of their stay including their rights and responsibilities. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 11 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, 8 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so they know how to support individuals to meet their needs and achieve their goals. Service users make decisions about their lives with assistance from staff where needed and are consulted on all aspects of life in the life. Service users are supported to take risks as part of a risk assessment framework to ensure their safety. EVIDENCE: Two service users records were sampled. These included an individual care plan that had recently been reviewed and updated where appropriate to reflect the individual’s changing needs. They detailed how staff are to support the individual to meet their needs with regard to their communication, eating and drinking, health needs including medication, finances, behaviour, mobility, personal care, relationships, emotional and psychological, religion and cultural and leisure opportunities. Service users, their relatives or friends, their key worker at the home and the day centre if applicable, other health professionals Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 12 and the Manager attend the review of their care plan. One service user had a review on the afternoon of the inspection visit. It was good practice that a member of staff spent part of the morning explaining the review and what sort of things the individual might want to discuss so that they understood what was going to happen. It is good that following the review a summary of actions agreed is written in a way that includes pictures so making it easier for the service user to understand. Care plans included details of the individual’s non-verbal communication. For example there was a table that stated ‘what is happening?’ What the person does?’ ‘We think it means’ ‘And we should’. Staff through getting to know the individual have written down their interpretation to try to help the person communicate as much as possible and help all staff to understand them. The care plans have been developed since the last inspection so that they are more person centred and are available in a format that includes pictures so that they are easier for service users to understand. Staff were observed throughout the visit giving service users choices about what they wanted to do, eat, drink or where they wanted to spend their time. Service users said that they could make decisions about what they do each day, in the evenings and at weekends. Information on advocacy services was available to service users. Regular service users meetings are held. The Tenant Participation Officer who is employed by Trident chairs the meetings. Written minutes of these are kept but they are also recorded on audio tape so that service users who do not read have an opportunity to have a copy. Service users talk about activities, holidays, the menu and how to make a complaint. Service users were asked at one meeting if they would like to be involved in interviewing staff and have since had interview training. A service user representative attends monthly ‘service sector’ meetings with service users from other Trident homes where wider issues can be discussed. One service user said, ‘staff always listen, I would not want to live anywhere else’. Service users records included individual risk assessments. These stated what action staff need to take to ensure that the risks to the individual are minimised as much as possible. For the two individuals case tracked there were wide ranging risk assessments in place, these included using public transport, manual handling, using public transport, eating and drinking, using bed sides, behaviour and responding to the fire alarms. All were satisfactory and regularly evaluated. Most service users are wheel chair users and therefore pressure sore risk assessments were available, these were subject to regular review. The CSCI had previously been notified of an Incident where a service user had put a coat hanger in their mouth, a risk assessment was completed soon after the incident. This included appropriate control measures to reduce risk. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that the people living in the home experience a meaningful lifestyle. Service users are offered a healthy diet and enjoy their meals. EVIDENCE: Most of the service users go to day centres and some attend college courses during the week. It was good that when snow closed the day centres service users had fun with staff making snowmen in the garden. Staff offered one service user karaoke activity during the visit, she obviously enjoyed it due to all the smiling and laughing during the activity. Staff said this was her favourite activity. Another service user was watching the television, staff came over and checked with him what he wanted to watch, showing him what was on the other channels. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 14 The diverse needs of service users is recognised in the activities offered, individual’s culture is valued and there are opportunities to share other people’s culture. Experiences on offer included the Irish Centre, Caribbean Heritage day and Banglea Mela. An activity board recorded activities that had been organised for Christmas, this included meals out, festivities at the Irish centre, disco, carols and a Pantomime. One service user said she was going away on holiday soon, to Cornwall. She said she had chosen the holiday destination. Information about contact with family and friends was available in service user care plans. Service users said they were supported to maintain contact with their relatives. One compliment received from a relative about staff supporting a service user to buy a Christmas present for his brother. Service users said that they clean their bedrooms, do the washing up and the cooking. Records showed that service users are supported to be as independent as possible by helping in household tasks. One service user was observed to be independently wiping down surfaces in the lounge, smiling as she did so. She was given lots of encouragement by staff throughout the task. The laundry is on the first floor and not accessible to the current service users. One service user said that they would like the washing machine brought downstairs so that they could be supported to do their own laundry. Menus show meals are nutritious. Food records showed meals are nutritious, including the recommended five daily portions of fruit and vegetables. Lots of fruit and fruit juice was available in the kitchen. The fridge was well stocked with food. It was good that there was lots of choice, for example skimmed, semi skimmed or full fat milk. One service user said ‘the food is good here, we get a choice’, but also said, “ I would prefer it if the work surfaces were lower down so I could help more in the kitchen”. Another service user said that they get to go food shopping with staff to choose food. Staff said that service users choose the menu in advance, this is done on a Sunday or Monday. They look at pictures of meals and decide what they want. A ‘Health Awareness Day’ is being planned in March. Staff said this was a link with a healthy eating café where they were looking at setting up a stall and event around healthy eating. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 15 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 and 20 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 so that service users receive personal support in the way they prefer and require and their health needs are met. The management of the medication protects service users so that they receive the medication they need, safely. EVIDENCE: The balance of gender and culture of the staff matched the backgrounds of service users to ensure they are supported by staff who can meet their needs. It is good that the gender sensitivity policy is available to service users in an easy read format so they know they have a choice of who supports them. Detailed information was available in care plans regarding individuals personal care needs, this included individual’s preferences about the gender of the staff who support them and cultural needs in regard to skin and hair care. One service user said she had a mobile hairdresser come and do her hair, she telephones to make the appointments herself. Another goes to a hairdresser who is able to meet her cultural needs regarding hair care. Discussion with a member of staff from the Day Centre who was visiting the home indicates that the service user who attends the centre is always well groomed. On arrival Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 16 home from the Day Centre staff supported individuals to take off their coats and offered drinks. One service user complained that the sun was in her eyes, staff immediately drew the curtain. Each service user has a moving and handling assessment that states how the risk to the individual and to staff are to be minimised to ensure they are as mobile as possible but not to the detriment of them or staff. Since the last inspection Health Action Plans have been developed for each service user. This is a personal plan about what an individual needs to stay healthy and what healthcare services they need to use. Some of this included pictures so making it easier to understand. Service users were referred to health professionals where appropriate. They had regular check ups with dentist, chiropodist and optician. Records of all appointments were kept including the outcome with any action that staff need to take to ensure the individuals health needs are met. Medication is stored in a locked cabinet. The cabinet was clean and organised into sections for each service user to help ensure that it is clear which medication belongs to whom. Staff who have been assessed as competent to administer medication give the medication to service users. There is a photograph of the individual at the front of their Medication Administration Records (MARS) to ensure that it is clear who to give the medication to. MARS cross-referenced with the blister packs indicating that medication had been administered as prescribed. Staff had signed the MARS appropriately. Where service users had been prescribed creams staff had dated on the cream when they had opened it to ensure that it does not exceed its shelf life. Where Controlled Drugs (CD’s) are prescribed for service users these are stored separately as required. Where service users are prescribed medication on an ‘as required’ basis protocols were in place stating when, why and how much should be given to the individual. Service users are not prescribed pain relieving medication on an as required basis such as paracetamol and homely remedies are not in use. Staff said they would take individual to the GP if they had a headache and needed paracetamol. This is not always practical and may delay an individual receiving pain relief, for example at weekends and bank holidays. It is recommended this is discussed with the GP and medication prescribed or the use of homely remedies agreed. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 17 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. Arrangements are in place to ensure that service users views are listened to and acted on. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The CSCI has not received any complaints about this home in the last twelve months. The home has also not received any complaints. Service users said that staff always listen to them and act on what they say. The complaints procedure is produced using pictures so it is easier to understand. Since the last inspection it has been displayed in the home as well in each service users file as recommended. It includes all the relevant and required information so that service users and their representatives know how to make a complaint. The complaints procedure is also discussed at service user meetings. Where appropriate there are behaviour management guidelines in place for service users who at times display behaviour that can be challenging. The Community Nurse is also working with staff and one service user due to some incidents of aggression towards another service user. Discussion with the Manager indicates that all staff receive basic adult protection training on induction and then attend a more in-depth course later on. It is good that the adult protection procedure is available in an easy read version for service users so it is easier for them to understand. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 18 Systems are in place to safeguard service users monies. A daily check of monies is completed, two staff sign this record. The Manager audits the records regularly. Service users spend their money on personal items and not on things that should be provided by the Provider. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 19 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, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is comfortable, generally clean and homely. Some further work is needed to ensure that it is accessible and meets the needs of all service users. EVIDENCE: Service users bedrooms contained many personal possessions. Bedrooms were warm and service users had sufficiently thick duvets for the season. Bedding was clean. One service user said that they have a key to their bedroom and they lock it. They also said they were getting some new bedroom furniture that they had chosen. At the last two inspections a requirement was made for the shower in one service users en suite to drain away efficiently as there was an offensive odour in this room. At this visit there was a pool of water in the showeroom in the afternoon that remained from having a shower in the morning. There was a strong odour of urine in this room. Following the visit a telephone discussion with the Manager indicates they have a meeting with a company to discuss products to clean the bedroom and shower room is hoped will reduce the odour. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 20 At the last inspection the sensory room was not being used due to the equipment requiring repair. This room is now used for activities and was in use for most of the visit. The open plan lounge and dining room are in good decorative order and are homely in style. The lounge is carpeted and there is a wooden floor in the dining room to make it more practical. Whilst the carpet is generally in good order this is spoilt by a iron burn. The carpet will therefore need repair or replacing. This home is intended to specifically meet the needs of service users who have a physical disability however some aspects of the design of the premises are not ideal. At the last inspection it was identified that one kitchen worktop had been lowered. However, service users had said that they were still not low enough for them to be able to help staff in the kitchen with the preparation of food. This remained the same at this visit. The worktops needs to be at a suitable height to meet the needs of all service users. Consideration should therefore be given too having an adjustable height worktop. The laundry is located on the first floor. One service user said she wished there was a downstairs laundry as she was quite capable of doing her own laundry and access upstairs is difficult. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 21 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 the home, their support and development are generally good and ensure that service user needs are met. EVIDENCE: The pre-inspection questionnaire stated that 50 of staff have NVQ level 2 or above in Health and Social Care. This meets the standard that at least 50 of staff should have this qualification. All staff interactions with service users were observed to be positive and encouraging. One relative commented on the CSCI survey ‘’wonderful ambiance..total confidence in staff’. Staff meeting minutes showed that these are held monthly. Staff discussed service users needs, holidays and activities, the language used in records, rotas, budgets, their roles and conduct. There were enough staff on duty at time of the visit to meet service user’s needs. A service user said that ‘there are always enough staff’. Previously the home has had a high reliance on agency staff. It is good that since the last Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 22 inspection more staff have been recruited. This means that service users are usually supported by staff that know them well. It was not possible to access staff recruitment records during the visit as the Manager was not on duty. Following the visit the Manager forwarded recruitment information for two members of staff. This was satisfactory and shows there is a robust procedure in place to protect service users from having unsuitable staff working with them. One service user said that they were involved in interviewing new staff. Service user meeting minutes show that they have had interview training, this is ongoing and they are hoping to watch a DVD about this at their next meeting. A new member of staff was spoken with. He said he had done a weeks formal induction and then worked shadow shifts in the home. He said he had done lots of training to include adult protection, manual handling, health and safety, fire, food hygiene and equality and diversity. Sampled staff training records show they get most of the training they need. Not all staff had done challenging behaviour training. Discussion with the Manager indicates that staff do Non Violent Crisis Physical Intervention training but that as part of the training program it is not scheduled until year two of their employment. Whilst the home does not have high levels of challenging behaviour there have been some notified incidents in the last 12 months. Staff therefore need appropriate training earlier in their employment to ensure they have the right skills and knowledge to manage behaviour. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users can generally be confident that their views underpin all self-monitoring, review and development by the home. Arrangements are in place to ensure that the health, safety and welfare of service users is promoted and protected. EVIDENCE: The Manager has many years of experience of managing care homes for people who have a learning disability. The Manager has the Registered Managers Award and NVQ level 4 in Health and Social Care, this means she has the qualifications needed to manage the home. A representative of the provider visit the home monthly to undertake an audit as required under Regulation 26. A copy of the report of this visit is sent to the CSCI. These include the views of service users. Trident has a detailed quality Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 24 assurance system. This assesses the quality of care, staff, the environment and management and the organisation. It considers the views of service users and their representatives. The quality survey was discussed at the service users meeting in December, it was explained that the home is awaiting the results from this. Health and safety in the home is well managed. COSHH cupboards were observed to be locked. A COSHH file was in place, and an audit of products used had been completed. Water temperatures are checked daily, these were observed to be within safe levels. Where one service users shower had been too hot action had been taken to replace the shower. External doors in bedrooms now have a thumb turn lock as required by the Fire Officer, staff now have a master key to the bedroom doors so they can access the rooms in an emergency. The fire procedure was on display, this is now in an easy read format that includes pictures so that it is easier for service users to understand. Fire records showed that staff test the fire equipment weekly to make sure it is working. Regular fire drills are held so that service users and staff would know what to do if there was a fire. An engineer regularly services the fire equipment. A Corgi registered engineer had completed the annual test of the gas equipment and stated that it was in a satisfactory condition. An electrician had completed the annual test of portable electrical appliances to make sure they are safe to use. The five yearly electrical wiring test was completed and the electrician stated that it was in a satisfactory condition. Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 25 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 3 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 X 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 3 X Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 26 YES, THREE 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 YA24 Regulation 16(2k) 23(2) 23(2) 16(k) 23 (2) (n) Requirement The shower in one service users en suite must drain away efficiently. Outstanding requirement from 31/12/05. The lounge carpet requires repair or replacement. The unpleasant odour in one bedroom and en suite must be removed. The kitchen worktops must be lowered so that they are accessible to all service users. Outstanding requirement from 31/01/06. All staff must receive training in: Managing behaviour. Outstanding requirement from 28/02/06. Timescale for action 30/04/07 2. 3. 4. YA24 YA30 YA29 30/04/07 30/03/07 30/04/07 5. YA35 12(1b) 18(1a&c) 30/05/07 Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 27 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 YA20 Good Practice Recommendations Service users are not prescribed pain relieving medication on an as required basis such as paracetamol and homely remedies are not in use. It is recommended this is discussed with the GP and medication prescribed or the use of homely remedies agreed. An accessible laundry area needs to be provided for service users. Consideration should be given to an adjustable height worktop in the kitchen. 2. 3. YA24 YA24 Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ferndale Crescent, 10 DS0000016880.V322529.R01.S.doc Version 5.2 Page 29 - 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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