Inspection on 17/08/06 for Florrie Robbins

This inspection was carried out on 17th August 2006.

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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Florrie Robbins 25/07/07

Florrie Robbins 09/02/06

Florrie Robbins 30/08/05

Florrie Robbins 17/02/05

Florrie Robbins 05/08/04

Florrie Robbins 28/03/04

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 Florrie Robbins Penshurst Avenue Handsworth Birmingham West Midlands B20 3DQ Lead Inspector Gerard Hammond Unannounced Inspection 17 August 2006 09:15 th Florrie Robbins DS0000016728.V299765.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 Florrie Robbins DS0000016728.V299765.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. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Florrie Robbins Address Penshurst Avenue Handsworth Birmingham West Midlands B20 3DQ 0121 331 1817 F/P 0121 331 1817 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) Mr Roger Murray Mr Paul Murray James White Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Florrie Robbins DS0000016728.V299765.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 9th February 2006 Brief Description of the Service: Florrie Robbins is registered to provide accommodation, care and support for up to five adults with learning disabilities. The Home is owned and run by Alphonsus Care. The property is a purpose built detached house lying to the rear of one of the Organisations other homes (Charles House, Birchfield Road). The ground floor of the house is suitable for people with significant mobility problems. The Home has its own front entrance on Penshurst Avenue, but the rear of the property can be accessed through the back garden of Charles House. The house is within walking distance of the centre of Perry Barr, and there is a wide range of community facilities in the area, including shops, pubs, restaurants and places of worship. Public transport links are particularly good, with a choice of several buses, and also a train station. All of the single bedrooms have en-suite shower facilities and wash hand basins. Downstairs are two bedrooms, a lounge, dining room, and kitchen. There is also a bathroom and separate w.c. Upstairs there are three more bedrooms, another bathroom, shower room , and w.c., the laundry, and the office. There is limited off road parking at the front of the house, and a private small lawned garden to the rear of the property. The current range of fees is £880 - £1100 per week. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information from a range of sources has been used to compile this report. The Manager submitted a completed pre-inspection questionnaire and supporting documentation. Previous inspection reports and information provided by the Organisation were also referred to. An unannounced visit was made to the home. Personal files and care plans, staff records and safety records were sample checked. A tour of the building was also completed. The Manager was formally interviewed, and four other members of staff seen informally. The communication support needs and learning disabilities of the people who live in the house make it difficult to consult directly with them to ascertain their views. Following the visit, the Inspector was able to speak with relatives and advocates to obtain their views of the service. Thanks are due to all those who contributed to this inspection for their cooperation, support and hospitality. What the service does well: What has improved since the last inspection? Some efforts have been made to meet requirements made at the time of the last inspection. Substantial work has been done to refurbish communal areas in the house, and these have improved the home environment considerably. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 6 Reports required under Regulation 26 (Care Homes Regulations 2001) are now up to the necessary standard. What they could do better: Residents’ contracts need to be updated. Care plans are still in need of development. Information should be current, and plans should provide sufficient detail to show exactly how support should be given. Plans should also include individuals’ agreed goals: some work needs to be done to develop these further so that outcomes can be measured. These should be considered when the plan is reviewed, which should be at least every six months. When plans are reviewed, a written record should be kept, showing who took part and how decisions were made. It should also show whether or not goals set previously have been achieved. It is most important that individual communication guidelines are developed, and that staff are trained and supported in alternative methods of communication. All of the points above were made at the time of the last inspection: action should now be taken so that real progress is made in these areas. There should be clear links between care plans and risk assessments: this can be achieved by numbering and indexing plans and assessments, and crossreferencing them. Activity planning and recording also continues to be in need of significant improvement, as reported at the time of the last inspection. There should be clear links between individuals’ assessed needs, their care plans and activity opportunities. It should be clear how and why particular activities are chosen. The staff training and development plan should reflect training needs related to the specific assessed care needs of the residents. In particular, for the people living at Florrie Robbins, this should include training in supporting people with Autistic Spectrum Disorders and also people with communication support needs. It is also recommended that staff receive training in person-centred approaches. Practice with regard to auditing medication stocks is in need of review. Records must show precisely and accurately the amounts of medicines held at any given time, and this should be subject to random audit checks, to safeguard residents and staff. All prescribed PRN (“as required”) medication should have a written protocol to guide staff about when and how medication should be administered, and in what circumstances. Creams and lotions should be clearly labelled with the date of opening and disposed of after 28 days. Members of staff who have been registered to study for NVQ level 2 for over four years should be supported to complete this training as soon as possible. Florrie Robbins DS0000016728.V299765.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. Florrie Robbins DS0000016728.V299765.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 Florrie Robbins DS0000016728.V299765.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, & 5 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. Prospective residents have opportunities to visit and try out the service prior to any decision about placement. Residents have contracts but these require updating and development to comply with National Minimum Standards. EVIDENCE: There have been no admissions to the home since the time of the last inspection. Sample checking of residents’ files indicate that assessments were reviewed by social workers recently. A discussion took place with the Manager concerning the process to be followed in the event of receiving a referral for placement. An appropriate admissions system is in place, and this includes opportunities for prospective residents to visit and stay over, so as to inform decisions about whether or not to use the service. It was noted that residents’ contracts are dated 2003 and unsigned. These require updating and development to comply fully with National Minimum Standard 5.2 (i-viii). Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in need of development to improve detail and enhance goal setting, so that residents’ assessed needs and aspirations can be met appropriately. Residents are supported to make choices about simple day-to-day things: developing the care team’s communication skills could enhance this further. Residents are supported to take risks, but risk assessments need to be developed and clearly linked to care plans to make this more effective. EVIDENCE: Sample checking of residents’ personal files showed that care plans continue to need development, as indicated at the time of the last inspection. It is important that plans are effectively reviewed so that information remains current. The plan for one individual does not allude to current eyesight problems and how this is affecting support when out in the community. His support plan for shaving says “with little support”, but doesn’t say what this is Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 11 or whether he prefers wet/dry shave etc. There were no clear links between needs assessments, care plans and day activities programmes. There is some evidence of attempts made to set goals since the last inspection, but this is limited and it is not always possible to see how goals will be achieved or how they can be measured. One person’s goal said “to fully understand his daily guidelines now in place” but doesn’t explain how this might be accomplished. Another said “white board to be regularly updated with (N)’s involvement” but doesn’t say how often or how he will be involved. Other examples of goals were “encourage to access local community more” and “give opportunity to assist in garden” (it was noted that photographs of what this activity involved were present). Objectives need to be clearly measurable, show how they might be achieved, and be time limited. Another person’s records show that he “enjoys social activities and likes to participate in homebased and community activities”. This should lead naturally to a goal, e.g. identify activities and indicate how often to try etc. Another said, “Awaiting exercise programme to strengthen (N)’s legs” but doesn’t indicate who is doing this. The record also shows “has not attended any religious services, but will have opportunities in the near future”. In both these instances, needs have been clearly identified, but opportunities to set goals have been missed. There are good planning and review tools available within the organisation, and these could be better utilised. One person’s plan is shown as having been reviewed by the Manager but there were no minutes or indication of who took part or record of decisions taken and how these were reached. It was also noted that there is little evidence of the use or development of person-centred approaches. Whole care plans should be reviewed at least every six months, with a written record maintained, showing who takes part and how decisions have been made. Individual goals should be evaluated at this time, and judgements made about what has worked or been achieved, and what might need to changed. Previous inspection reports have highlighted the importance of appropriate communication guidelines for working with people with high communication support needs. Draft guidelines currently in place are the same on all residents’ files. These need to be personalised for each individual. Guidelines should give specific examples of gestures, behaviour etc. and indicate what these mean for that person. The importance of good quality information on how individuals communicate cannot be overstated when supporting people with complex care needs, as this underpins all other activity. Consideration should be given to developing the use of alternative methods of communicating such as pictorial aides and objects of reference, so as to improve individuals’ capacities to make choices. It was noted that a picture menu book was present in the kitchen, but the Manager indicated that this was not currently in use. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 12 Risk assessments continue to require development. There should be clear links between care plans and risk assessments – simple indexing and crossreferencing is one of the easiest ways of achieving this. It was noted that there was a risk assessment for one person about choking, but there was no mention of this in care plans for eating/drinking or diet. It is important that, having risk assessed a given situation appropriately, that the process is correctly used to inform the current care plan, usually by inserting the control measures devised. It was further noted that some “read and sign” sheets need updating. The use of “read and sign” sheets is good practice, but can only be effective if these are kept up to date. A risk assessment is still required for the resident using bedrails. The residents all have significant communication support needs, so choices tend to be restricted to fairly simple things (see Lifestyle also). Staff were observed asking people about what they would like to drink, and later about their choice of a takeaway meal for that evening. Florrie Robbins DS0000016728.V299765.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to access their local community and to take part in activities away from the home, but it is not possible to assess accurately the quality of opportunities available due to poor recording. Residents are supported to keep in touch with families and friends. Residents enjoy a balanced, varied and sufficiently nutritious diet. EVIDENCE: People living in the house continue to access activities outside the home on a daily basis during the week. Some attend local centres, and the organisation has its own day service “arm”. As previously reported, it is difficult to assess accurately the quality of lifestyle opportunities that people enjoy, as recording about these things is limited or non-existent. There are few direct links between plans and activities, which should present significant potential for appropriate goal setting. It is not possible to tell how choices have been made about what activities are undertaken. It should be possible to arrange for Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 14 reporting within the organisation so that appropriate information about day activities is shared, so as to inform future care planning. It is not possible to tell how is this being linked to quality assurance and monitoring processes. Daily records tend to be confined to things like watching TV, getting drinks, and assistance with personal care. There are few references to other activities undertaken at weekends or in the evening. A requirement was made at the last inspection that activity recording should be expanded and developed to take these issues into account, and this remains outstanding. The Inspector was able to get in touch with relatives for all of the residents, following the visit to the home. All confirmed that they are able to maintain contact appropriately, and that residents were supported to maintain this, in accordance with the wishes of those involved. Food stocks were examined and supplies were ample, including fresh fruit and vegetables. The record of meals taken indicates that residents have access to a balanced diet that is sufficiently varied and nutritious. The size of the home facilitates choice, and residents were observed choosing takeaway options. Florrie Robbins DS0000016728.V299765.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 at least once during a 12 month period. 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. Residents are supported with friendliness, warmth and respect, and their healthcare needs are generally met. Developing Health Action Plans could improve this further. Current practice with regard to medication needs to improve, so as to safeguard residents’ health and welfare. EVIDENCE: Residents’ attire and personal grooming provided evidence that a good basic standard of care is given. Staff were directly observed interacting with residents: their manner was warm and friendly, and support is given in an appropriately respectful manner. Personal records provide evidence of involvement of members of the multidisciplinary team including GP, Consultant Psychiatrist, Dentist, Physiotherapist, Chiropodist, Optician and Continence Advisor. Referrals are made to primary and specialist healthcare professionals in accordance with individual needs. It is recommended that personal Health Action Plans be developed for each person living in the home, to enhance current practice. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 16 The Medication Administration Record (MAR) was checked and duly completed: there is a good system in place for ensuring that medication is dispensed appropriately, requiring double-checking and two signatures. However, the record of people authorised to administer medication needs to be updated to include sample signatures. Protocols should be put in place for all prescribed PRN (“as required”) medication. Ideally, these should be agreed with and countersigned by the prescribing doctor. The system for auditing medication stocks requires an overhaul. Current records only show quantities of tablets being checked in: this should also show the amount carried forward from stock already held, and the total new balance. Medication stocks should be subject to regular audit, for the protection of residents and staff. Creams and lotions should also be marked with the date of opening and it is recommended that the date for disposal should also be recorded to ensure appropriate practice. Florrie Robbins DS0000016728.V299765.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is difficult to assess accurately residents’ views, due to their learning disabilities and communication support needs. Appropriate complaints procedures are in place but these are not generally accessible to the people living in the house, for the reasons stated above. General practice supports the prevention of abuse and protection of residents from neglect and self-harm. EVIDENCE: As previously reported, residents’ communication support needs mean that it is difficult to assess their views. Residents’ meetings are held on a regular basis and there is a format for exploring relevant issues. This is in the form of a questionnaire that asks would you like to speak to staff alone? any problems? Is there anything you would like to change / happen? Are you happy with your food? Do you want to go somewhere different? It is difficult to see how this is being made relevant for this group of residents in view of their individual communication needs, and reinforces the point made earlier about good guidelines and promoting alternative methods of communication. Almost all the staff team have had recent training in Adult Abuse / protection and an appropriate policy coupled with local multi-agency guidelines is in place. A conversation took place with the Manager about the need to report incidents under Regulation 37 (Care Homes Regulations 2001)–it was noted that none have been received since the last inspection. Residents’ personal money records were sample checked. Amounts held tallied with the record, which was appropriately supported by receipts. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the benefit of living in a house that is comfortable, homely and safe. People’s rooms and bathroom and toilet facilities suit their individual needs and promote privacy and independence, complemented by communal areas. Specialist equipment to maximise independence is also provided. The house is clean, tidy and hygienic. EVIDENCE: A tour of the building was completed. The house has been significantly refurbished in communal areas since the last inspection. The lounge has been redecorated, a new carpet fitted, and new furniture and light fittings installed. Things have been moved around to make best use of available space. The dining room and the hallway, and the downstairs bathroom have also been redecorated. The carpets in these areas could do with cleaning. Repairs have been made to the kitchen tiles (edge / border fitted as temporary measure) and the Manager advised that kitchen is scheduled for refit as soon as funds are available – it is hoped that this will be within the next 12 months. Efforts have been made to improve the garden including painting the fence in a bold and colourful design (done by one of the residents, with help), creating Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 19 bedding areas for plants and shrubs and providing some new baskets and pots. The resident in question is said to have enjoyed this greatly and it is intended to continue to build on this for the future. It was noted that the roof windows in the office and first floor shower room / toilet need a coat of wood stain / varnish. Residents’ own rooms are individual in style and include personal belongings and ornaments. Individuals benefit from the provision of en-suite facilities in their rooms, enhancing their privacy and independence according to individual needs. A new bed with fitted rails has been provided for one resident and another has had a new walking frame that has helped improve mobility around the house. Previous requirements relating to the garden, the kitchen and cleaning extractor fans in the house have all been met. The house is generally maintained to a high standard, and kept clean, tidy and hygienic. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are generally competent and have access to a good range of training opportunities, but identified gaps in training should now be addressed so as to improve the quality of support to people living in the house. Residents are generally protected by the service’s recruitment policies and practice, and benefit from being supported by staff that are supervised regularly. Staff appraisals should be used to ensure that training opportunities are taken up and completed appropriately by all members of the care team. EVIDENCE: Direct observations of staff interactions with residents provide evidence that they have a good relationship with people in their care and a good general understanding of their needs (see next section also for comments made by relatives and advocates). The current training plan for the care team shows that one senior member of staff is qualified to NVQ level 3. One other member of staff who works nights is qualified to NVQ level 2. Five other members of staff are shown as registered for NVQ level 2. Two of these are recent registrations (June 2006) but the other three date back over four years. One of these is a Senior and another first registered in 2001. All of the staff team are shown to have completed Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 21 Learning Disability awards Framework (LDAF) training (x 10) or to be registered for it (x3). It should be noted that LDAF training is designed to be complementary to NVQ ‘s, not to replace them. Members of staff also have a personal responsibility to ensure that they continually update their skills and learning. The organisation offers a rolling programme of training for staff in all its homes and take up of opportunities appears generally good. It was noted at the time of the last inspection that no one on the staff team apart from the Manager has done any training in supporting people with Autistic Spectrum Disorders, and there has been no change in this situation since then. This training is of particular significance, given the assessed needs of people living in the house. In the same way, training in alternative forms of communication should be provided for staff, and this should be included in the home’s training and development plan. It is further recommended that staff receive training in the use of person-centred approaches, in keeping with the aspirations of “Valuing People”. Records relating to the recruitment of the most recently appointed member of staff were sampled: all of the required documentation was in place. However sample checking of the records for another member of staff who transferred from another home in the organisation showed that documents required to establish this person’s right to remain in the UK had expired (May 2006). This must be followed up and appropriate documents obtained. Formal supervision and staff appraisals are scheduled, and checking of files provided evidence that this is up to the required standard. However, action should now be taken through the supervision and appraisal process to address the issues relating to staff that have not yet completed NVQ training that they have registered for over four years ago. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is generally well run. A report of quality assurance and monitoring activity is still required, so as to demonstrate how residents’ views can be considered, and how these underpin service development. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: The Manager is qualified to NVQ level 4 and holds the Registered Manager’s Award. He is also a qualified Assessor for NVQ students. Staff report that the Manager is approachable and that his style of management is open and inclusive. One said, “you know where you are with him”, and another “he is firm, but fair”. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 23 Reporting under Regulation 26 (Care Homes regulations 2001) is now generally up to standard, since the current Service Manager became well established in her post. As indicated earlier in this report, discussions were held with the Manager about reporting under Regulation 37 (none received since last inspection). As it was not possible to seek residents’ views directly, due to their communication support needs and learning disabilities, the Inspector contacted family members and advocates by telephone after visit. Comments received about the service included “he’s much happier than at the previous placement” and “Staff keep me notified” Also, “Carers are pleasant and welcoming” and “I think that it is a good home”. “It’s brilliant”, “The food is good, staff are very helpful and the home is clean and tidy” - “it’s brilliant –10/10” “The best home he’s been in”. “Staff are brilliant, I couldn’t fault them” “They phone me up and keep me informed, I’ve never had any complaints. “ My (family member) is treated well”. As previously reported, managers from other homes in the organisation conduct quality audits on each other to give an outside view of the service. A previous requirement that information on Quality Assurance activity should be collated, analysed and reported on remains outstanding. A sample check safety records was carried out. The fire alarm and fire fighting equipment have been serviced, and regular checks on the fire alarm and emergency lighting systems carried out and recorded, as necessary. The fire risk assessment has been reviewed. The local Fire Officer visited recently: a report has not yet been received, but the Manager advised that verbal feedback given indicated that no requirements were to be made. Fire drills have been carried out in March, April, July and August. Records of checks on fridge, freezer and water outlet temperatures are all complete. Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 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 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 2 X X 3 X Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA5 YA6 Regulation 5 (c) 15(2b) 17(3a) Requirement Update existing service users’ contracts in accordance with National Minimum Standard 5.2 Develop existing care plans as indicated in the main body of this report: set targets and review as appropriate. Include detailed communication guidelines for each resident. (Outstanding since 30 November 2005.) Cross-reference risk assessments to relevant care plans, and vice versa. Develop risk assessment for use of bed rails. (Outstanding since 31/05/06) Further develop residents’ activity opportunities and provide appropriate staff support to facilitate this. Expand activity recording to demonstrate clear links to individuals’ assessed needs and wishes, and to their personal goals. Evaluate activity opportunities in detail when care plans are reviewed. (Outstanding since 31/05/06) Timescale for action 31/10/06 31/10/06 3. YA9 13(4b-c) 31/10/06 4. YA12 YA13 16(2m-n) 18(1a) 31/10/06 Florrie Robbins DS0000016728.V299765.R01.S.doc Version 5.2 Page 26 5. YA20 13 (2) 17 6. YA20 13 (2) 7. YA20 13 (2) 8. YA34 19 9. YA35 18(1a,c) 10. YA39 26 24 (2) Review procedures for recording and auditing medication stocks. Ensure that a full and accurate record of all medication stored in the home is maintained at all times. Conduct random audit checks of medication stocks, and keep a record of when these have been carried out. Protocols must be put in place for all prescribed PRN (“as required”) medication. These should be agreed with and countersigned by the prescribing doctor. Ensure that all creams and lotions are labelled with the date of opening and disposed of within 28 days of that date (or before if required). Obtain documentary evidence of staff member’s residency / work permit status and forward a copy to CSCI Make arrangements for members of the care team to receive training in supporting people with Autistic Spectrum Disorders, in accordance with residents’ assessed needs. (Outstanding since 31/05/06) Produce a written report evaluating Quality Assurance and Monitoring activity, demonstrating how service review and development is underpinned by residents’ views. (Outstanding since 30/04/06) 30/09/06 30/09/06 30/09/06 30/09/06 31/10/06 31/10/06 Florrie Robbins DS0000016728.V299765.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 YA6 Good Practice Recommendations Plan to record all current information about how individual residents communicate, and incorporate into communication guidelines for each person. Seek help to develop the capacity of the team to enhance communication opportunities for residents. Review and update “read and sign sheets” to ensure that staff have most up to date information concerning residents’ risk assessments Develop Health Action Plans for each resident Expand training opportunities in care management practice and the use of person centred approaches to additional members of the care team. 2. 3. 4. YA9 YA19 YA35 Florrie Robbins DS0000016728.V299765.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Florrie Robbins DS0000016728.V299765.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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