Inspection on 26/01/07 for 115 Gough Road

This inspection was carried out on 26th January 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

115 Gough Road 26/03/08

115 Gough Road 29/11/05

115 Gough Road 05/07/05

115 Gough Road 29/11/04

115 Gough Road 06/05/04

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 Gough Road, 115 Edgbaston Birmingham West Midlands B15 2JG Lead Inspector Peter Dawson Unannounced Inspection 26th January 2007 10:00 Gough Road, 115 DS0000016712.V325732.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 Gough Road, 115 DS0000016712.V325732.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. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gough Road, 115 Address Edgbaston Birmingham West Midlands B15 2JG 0121 446 6744 0121 446 6289 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 *** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 Brief Description of the Service: 115 Gough Road is a large detached Victorian house situated in a quiet residential road in Edgbaston. Public transport is close by and the home is approximately two miles from the city centre of Birmingham. Gough Road currently accommodates five male service users. The accommodation is spacious and includes a large reception hall, lounge, dining room, kitchen, office/meeting room, laundry and a ground floor bedroom with ensuite facilities. Four further bedrooms, (one of which is ensuite), two bathrooms and a toilet are situated on the first floor. The home has a second floor, which is inaccessible to service users, and provides a storage area and a staff sleeping in room. The garden has been developed so that the top area includes a large patio area which is accessible to service users and contains garden furniture and a range of plants. The lower part of the garden is extensive. The home provides care and support services to five adults with learning disabilities and a sensory impairment. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one inspector on day from 10 am – 5.30pm. The Manager was not on duty but time was spent talking to all staff on duty and observing practices and interactions. None of the residents have verbal communication so were not able to express a view of care. A pre-inspection questionnaire was received from the service prior to the inspection and provides a basis of some information in this report. Written feedback was not obtained from relatives or visitors. There was an inspection of the whole of the physical environment and records relating to the inspection process were accessed including care plans, risk assessments, staff rota’s, medication records, fire records. Weekly fees for residents at Gough Road are £1,543 - £2,992 per week. What the service does well: What has improved since the last inspection? The statement of purpose and service users guide have been reviewed and updated. Risk assessments have also been developed further in some areas. They are now regularly reviewed. There is now a count of all medication allowing an audit trail of the system. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 6 Behavioural issues identified in the last report between residents has been satisfactorily addressed. Some outstanding repairs/maintenance issues have been resolved/completed. A new kitchen was installed in February but showing signs of poor quality/durability and now likely to be further replaced. The use of agency staff has been drastically reduced with the appointment of permanent and bank staff. This provides greater continuity for residents. A new Registered Manager was appointed to the service in January 2007. Adjustment to the dining room fire door has been carried out and hot water temperatures in all outlets monitored closely. What they could do better: Contracts must be provided for all residents. A review of eating/drinking guidelines and relevance to behavioural guidelines must be carried out urgently. Transport must be available at all times to match the recreational needs of residents. Protocols for “as required” (PRN) medication must be reviewed and dated. Outstanding repairs/maintenance to the environment must be pursued urgently with the owners of the property. The toilet on the ground floor is not fixed to the floor and is unsafe. Statutory and other training for all staff must be arranged as soon as possible – previous requirements have been made. Regular fire drills must be provided for all staff and residents with clear instructions of actions in the event of fire. A risk assessment must be provided immediately in relation to the location of the cooker. The possibility of re-location should be considered. Staffing levels should be maintained at levels to ensure safety of residents at all times and access to community facilities. Gough Road, 115 DS0000016712.V325732.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. Gough Road, 115 DS0000016712.V325732.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 Gough Road, 115 DS0000016712.V325732.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): Standards 1 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Requirements to update information about he home have been met. Information is in suitable formats. Confirmation in writing required to confirm residents have signed contracts. EVIDENCE: In compliance with a requirement of the last inspection, the Statement of Purpose/Service Users Guide has been revised and updated to include all required information. There is a complaints procedure with the guide and also a pictorial complaints procedure, audio/CD of the procedure and Braille version also available upon request. In the absence of the Manager it was not possible to confirm that all residents have a signed contract as required in the last 2 reports. The home must confirm in writing to CSCI that this requirement has been met. There has not been an admission to this home for the past 3 years. It was therefore not possible to assess the pre-admission procedures. Gough Road, 115 DS0000016712.V325732.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,9 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There has been further work on care planning information and risk assessments. There are still some gaps, review of risk assessments required in relation to behaviour and use of kitchen. EVIDENCE: Care plans were sampled relating to 2 residents. Information was generally good and included required information detailed in personal profiles and specific needs to address communication and living skills. There was considerable information. The presentation could be improved to include a more detailed index to easily identify areas of need. Preferred routines, likes/dislikes and hopes/aspirations were documented. Some information related to night time activity but it is recommended that a short, concise statement of night time care needs should be provided for each resident. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 11 The SENSE format for daily notes on each resident is excellent and provides the required details of care provided. These had been completed in detail and were a clear record of the daily care provided for each resident. Risk assessments have been improved in light of a previous requirement and document the level of risk. Both care plans and risk assessments are reviewed on a monthly and 6 monthly basis. There was a shortcoming in relation to one resident. The eating & drinking guidelines stated that after a specific time in the evening further snacks/food should not be given. The resident had made several requests for further food but been refused. This precipitated an incident of “challenging behaviour” and referral to the “ Behaviour Guidelines”, the relevance of this was not clear – ultimately food was given to resolve the situation. Clearly the eating & drinking guidelines for this person must be urgently reviewed and also any reference to the behaviour guidelines clarified. A clear strategy must be in place. Risk assessments relating to use of the kitchen must be reviewed for all residents –further information is given under Standard 42 of this report. There is a policy/procedure relating to confidentiality. Records are secure and confidential. Care staff showed restraint in discussions when residents were present. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11 - 16 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents received good support from staff in chosen lifestyles. There is a range of innovative activities but transport availability must be reviewed. EVIDENCE: Many positive examples were seen during the inspection relating to resident choice and lifestyles. A resident who does not sleep until the early hours of the morning sleeps on the lounge settee by choice and not pressured when he refuses to go out in the morning. A resident who constantly climbs and suspends himself above ground floor level for long periods is allowed to do so. He requires constant 1:1 care throughout the day. A platform has been built in his bedroom to accommodate this need with plastic re-enforced sheets to protect him from the windows. A resident with repetitive/compulsive behaviour demands to go to Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 13 McDonalds daily for a drink. He is supported in this on a daily basis by staff which satisfies his compulsive need. Each person has a daily schedule of activities throughout the week. Activities are varied and include swimming, skating, canoeing, rock climbing, massage, shopping etc. At the time of the last inspection it was assessed that 82 of activities had been accessed as planned in a random check, this had been an improvement on the previous inspection. A survey of activity for one resident on this inspection showed that in the current month Ice skating (weekly activity) had not been accessed at all due to safety instructor being away from work. Bowling had only been accessed once and on one occasion recorded not accessed as no driver was available. It is important that activities take place as planned and where no driver is available taxis are used. There are now 2 vehicles which staff are prepared to drive rather than a previous larger vehicle. Records show that 5 staff have completed required driver training out of a total of 16 permanent staff. Either more drivers or greater use of hired transport are needed. Problems are particularly evident at weekends when there has been some reduction in the numbers of staff on duty to 3 during the daytime. There are some opportunities for personal development. Staff were seen to assist 3 residents in preparing drinks in the kitchen. Sensory impairments inevitably limit some opportunities but staff take opportunities to extend skills where possible. Trips to the community include walks, rambles, shopping visits to cafes and leisure centre. Each week 3 resident enjoy a morning at the leisure centre swimming baths which has a gradient to walk into the water and also wave machine which residents enjoy. Many activities are accessed from the Birkdale Centre and Garden Room – facilities provided centrally for residents of all SENSE homes by the Sense Organisation in Birmingham. Family contacts are promoted where possible and frequency limited only by family availability and distance. Four residents have ongoing family contacts. One has monthly family visits supplemented by e-mail and telephone conversations. This person went home at Christmas. The extreme is a resident with no family contact having been in care for many years. Currently staff are researching family contacts and history. Holidays are provided by the home. A contribution of £300 is provided for each person in addition to staffing and transport. Finance is not a problem in this area. This year separate groups went to Scotland and Derbyshire. Additionally there have been day-trips to places of interest including Drayton Manor Park and Weston Super Mare. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 14 There is a sensory room in the home which is presently being refurbished and additional facilities provided. All staff on duty were seen to treat all residents with total consideration and respect. This included automatically knocking upon bedroom doors and also when a resident kicked over the foot-spa, flooding the dining room. Food provision indicates a varied and interesting diet. Residents individual likes and dislikes are known and recorded. Two residents are Muslims and recent mistakes made - but subsequently realised when visiting McDonalds restaurant. Hal Lal foods are provided in the home with clear written definitions of the foods which can be eaten. Gough Road, 115 DS0000016712.V325732.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): Standards 18 – 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Procedures and instructions for providing personal care were in place and good. Health care needs are well defined and met. Some omissions in relation to medication have been investigated and will be reported to CSCI. EVIDENCE: Varying degrees of personal support are required for all residents. This is well defined in care plans. Personal care was seen throughout the inspection to be provided with sensitivity and ensuring the privacy and dignity of individuals. There are generally high dependency needs in this home. All residents have multi-sensory impairments, none have verbal communication. Communication is by means of symbols/objects of reference, signs BSL, Hand over Hand. Staff were observed to have good communication with residents and there were positive responses to approaches by staff. One resident has particularly high dependency needs and requires 1:1 support at all times during the day. This was seen to be given consistently and more Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 16 importantly, unobtrusively - When the resident was engaged in activity in his bedroom staff would sit and complete paperwork then one member of staff hand over to the next without dialogue – the change was automatic, unnoticed and retained flexibility for staff. Two residents regurgitate food, presenting a choking risk also. Speech & language assessments had been carried out by specialists and care instructions were clear. There are implications for weight and records showed that weight had been monitored on a regular basis with referral to health professionals defined in the event of severe weight loss. The home has the services of a local GP practice, all are registered there. The GP has known the residents for many years, some from other settings and reported to provide a good service to the home. Chiropody and dental services are accessed through specialist Learning Disability services as required. Psychiatrist from Greenfields centre involved with two residents also. Vision and audiology tests had been carried out as required. Medication is supplied to the home in blister packs (MDS) by Boots chemists and is appropriately stored. There is an audit form to record all medication received/administered/returned allowing audit of the system. Medication Administration sheets seen had been completed accurately and satisfactorily. There are several items prescribed “as required” (PRN) – a requirement of the last report was to update and review the protocols for PRN medication. This has not been done and is a further requirement of this report. Staff training in relation to medication is in place. Those administering medication have received certificated training and assessment by senior Sense manager. It was noted that there had been errors in medication administration on two occasions since the last inspection – this related to medication not being given in 2 instances. These matters are being investigated by Sense Managers and outcomes reported to CSCI when finalised. Meanwhile staff involved are not allowed to continue administering medication until the outcomes are known and resolved. Gough Road, 115 DS0000016712.V325732.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): Standards 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The complaints procedures/vulnerable adults procedures have been tested since the last inspection and found to be robust. The home has responded very positively to a threat to the safety of a resident. Protection of residents is good. EVIDENCE: An incident identified in the last report with a requirement to review behaviour guidelines in relation to aggression by a resident have been addressed. New guidelines are in place and there has been no repetition of the behaviours and risks to other residents. There is a complaints procedure available in the home and available also in alternative formats. The home had correctly reported an incident under the Vulnerable Adults procedures. This related to an external threat to the welfare and safety of a resident. Closer supervision and heightened awareness of a potential threat was deployed by the home. A communication book established to report all incidents and 2 weekly updates provided for the family at their request. Gough Road, 115 DS0000016712.V325732.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 – 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the environment require action and maintenance by the Housing Association. The layout and facilities of the building meet the needs of residents. EVIDENCE: The premises are not owned by SENSE. Owners of the property are Moseley & District Housing Association (M&D). The building is generally of good size. There is one bedroom on the ground floor and adequate communal space including lounge, kitchen and dining area. There is also a laundry and office area conveniently situation at the front of the building. There is a large private garden area at the rear with patio on 2 levels, with a lift to the lower level. This area reported to be much used in the summer months and is easily accessible for residents. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 19 Maintenance of the building could be vastly improved. At the time of the last inspection a new fitted kitchen was awaited. This was fitted in February 2006 but now requires considerable attention. Staff report the kitchen units are in fact all being renewed due to poor quality and durability. Requirements made at the last inspection to ensure repairs/renewals in 5 areas have been addressed but there is a further list of maintenance action required. These are all documented in the home, in Regulation 26 reports and have been reported to the owners M&D – examples are: no cold water supply to toilet area, no cord for extractor fan, damp in dining area, repairs to shower area, repainting etc. These matters are being pursued by SENSE General Manager and pressure should be applied for M&D to complete the work. Additionally the toilet in the ground floor area is not secured to the floor (moveable) and requires urgent repair. There are 2 bathrooms on the first floor with shower and adequate for residents needs. The ground floor bedroom has en-suite with shower. All bedrooms were seen and were of good size, some easily accommodating double beds. Personalisation was in place where acceptable and reflected individuality. The sensory room on the ground floor is presently being refurbished with additional sensory equipment. The heating was inadequate at the time of the last inspection but all areas of the home were adequately heated on this visit. Staff reported that there had been repairs to the boiler system. Action was taken after a resident recently left the building but safely returned before reaching the road. A risk assessment has provided a new audible alert for the entrance door and staffing levels taken account of the risk. There are plans to fit a keypad lock to the main door. Gough Road, 115 DS0000016712.V325732.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 –33 and 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 committed and professional. Many areas of statutory training require action. There are some shortfalls also in other areas of professional training. Residents are well supported by supervised staff. EVIDENCE: Staff on duty were seen to provide support to residents with patience and understanding. They were sensitive and professional in their approaches and responses. The Manager was off duty at the time of this inspection and all staff made a willing, positive and helpful contribution to the inspection process. It was clear from discussions with all staff that they enjoyed their work, had detailed knowledge of the needs of residents and quite committed to resident care. The numbers of staff on duty appears to vary. There have always been 4 staff on duty throughout the day but rota’s showed some reductions. On a recent weekend staffing had reduced to 3 throughout the day and had restricted some external activities, residents having to be home based. One resident requires Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 21 constant 1:1 care and the remaining people have fairly complex needs needing a higher staffing ratio. Sometimes at weekends there are 3 staff plus one 10 – 6 but this had not happened in the example given above. There is a programme of NVQ training and the home meets the required50 of NVQ trained staff. All are offered NVQ training and there is an expectation to engage in this study. A staff training matrix was provided prior to the inspection. Staff reported that there was now regular monthly supervision for all There are shortfalls in other areas of staff training. Areas requiring statutory training/updated training include: Moving & Handling, Fire Safety, Protection of residents and Health and Safety. These must be addressed and have been made subject to requirements on the last two inspection visits – timescales have not been met. Regular monthly staff meetings are held and records seen to confirm this. A requirement of the last report to reduce the number of agency staff working in the home and provide greater continuity for residents has been addressed. New staff have been appointed and also bank staff. SENSE are now recruiting centrally rather than individually for homes and this has improved the staffing situation at Gough Road. At the time of this unannounced inspection the Manager was not on duty. It was therefore not possible to have access to staff files. Recruitment procedures were therefore not inspected. Gough Road, 115 DS0000016712.V325732.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 38, 40, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a relaxed homely atmosphere. Action is required in relation to 2 areas of risk. EVIDENCE: At the time of the last inspection an Acting Manager was working in the home. In August 2006 a further Acting Manager was appointed from another Sense Home and ultimately approved by CSCI as the Registered Manager in the week prior to this inspection. She was not on duty at the time of this unannounced inspection, it was therefore not possible to objectively assess her management style and impact upon the home on this visit. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 23 Staff on duty did say that they were better informed about management issues following the appointment of the new manager. The manager provided informative information about area management meetings. Staff also said that they readily access information from the SENSE intranet website and were able to update themselves about news and changing procedures etc. The atmosphere in the home was relaxed and there was positive and open communication between staff and residents. Two requirements were made in the last report relating to Health & Safety issues – hot water outlet at sink in bathroom to be reduced to 43C and dining room door must close onto the rebate to ensure fire protection. A sample of hot water outlets confirmed adequately controlled temperatures and the dining room door has been adjusted to provide an adequate smoke seal. Areas of concern about Health & Safety of Residents identified during this inspection were: The electric cooker in the kitchen area is immediately left upon entering the kitchen and has ceramic hobs. All residents have access to the kitchen area and discussions with staff showed there were concerns about resident safety. – 2 residents have no sight and 3 have severe visual impairment it is impossible to constantly monitor entry of residents to the kitchen who proceed to use the kitchen units as a guide to move around. The risks are obvious. A risk assessment must be carried out immediately to address this issue and staff felt that the cooker could more safely be relocated to the far side of the kitchen to reduce the risk. This could be done when the expected re-fitting of the new units takes place in the near future. Fire records were seen and appropriate checks of the alarm system and servicing of equipment had taken place. However regular fire drills for all staff and including residents had not taken place. This is required. There was also some confusion in the records about the evacuation path from the building in the event of fire (front or rear entrance). This must be addressed in fire drills carried out. Additionally it was concerning that 11 staff had not had required annual fire safety training. A report from the Fire Officer following his recent visit was not available in the home although it is understood requirements were made. It was not possible to clarify this and the on-call Manager present at the end of the inspection will raise the matter with the Registered Manager when she is next on duty. Gough Road, 115 DS0000016712.V325732.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 3 2 X 3 X 4 X 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 2 25 3 26 3 27 2 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 3 12 X 13 2 14 2 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x x 3 x 3 3 2 x Gough Road, 115 DS0000016712.V325732.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 Requirement Timescale for action 31/03/07 27/01/07 3 YA14 4 YA20 5 YA24 6 7 8 YA27 YA35 YA42 Each resident must have a signed contract. 2 previous requirements not met. 15(2) Review eating/drinking guidance and behavioural guidelines to avoid situations of challenging behaviour. 16(2)(m)(n) Transport must be available to enable leisure activities. Where drivers are not available taxis must be used. 13(2) Protocols for PRN (as required) medication must be dated to show they are current. Previous timescale not met. 23(2) Outstanding repairs to various parts of the home must be pursued urgently with the owners of the property. 23(2)(c ) Ground floor toilet must be fixed to floor to ensure safety. 18(1)(c ) All staff must receive statutory training. 2 previous timescales not met. 23(4)(a)(b) Regular fire drills must be provided for all staff and residents. Clarification of evacuation path must be included. 28/02/07 27/01/07 31/01/07 27/01/07 31/03/07 07/02/07 Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 26 9 YA42 13(4)(a) Provide risk assessment in relation to access to cooker and consider relocation. S 27/01/07 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 2 Refer to Standard YA6 YA33 Good Practice Recommendations Provide night care plan for all residents. Staffing levels should be maintained inline with agreed and required levels. Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 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 Gough Road, 115 DS0000016712.V325732.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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