Inspection on 26/04/06 for 2 & 10 Grove Road

This inspection was carried out on 26th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 & 10 Grove Road 21/05/08

2 & 10 Grove Road 04/05/07

2 & 10 Grove Road 02/11/05

2 & 10 Grove Road 16/06/05

2 & 10 Grove Road 26/07/04

2 & 10 Grove Road 12/03/04

2 & 10 Grove Road 05/09/03

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

CARE HOME ADULTS 18-65 Grove Road, 2 & 10 Kings Heath Birmingham West Midlands B14 6ST Lead Inspector Kerry Coulter Unannounced Inspection 26th April 2006 09:30 Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Grove Road, 2 & 10 Address Kings Heath Birmingham West Midlands B14 6ST 0121 441 3221 0121 441 3541 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) Sense West Ms Mandy Lynch Care Home 8 Category(ies) of Learning disability (8), Sensory impairment (8) registration, with number of places Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years The home may provide care for up to 8 service users requiring personal care by reason of combined learning disability & sensory impairments 2nd November 2005 Date of last inspection Brief Description of the Service: Grove Road is located in a small cul-de-sac in a residential area of Kings Heath. The Home comprises of two purpose built properties each accommodating up to four service users with learning disability and sensory impairment. Grove Road is within reasonable walking distance of the main shopping area of Kings Heath, where there are numerous shops, public houses, restaurants, churches and recreational amenities. There is a large park close by and public transport is easily accessible. 2 & 10 Grove Road is on opposite sides of the cul-de-sac. Each house has a lounge and a separate dining room, a modern fitted kitchen and a small laundry room. The administrative office is located at number 2 and the staff sleeping in room at number 10. Number 2 also benefits from a conservatory, which gives additional space. All service users’ bedrooms are of single occupancy and are decorated and furnished to reflect individual interests and personalities. There are bath and shower facilities in the upstairs bathroom plus separate toilets on the landing and on the ground floor. Both homes are comfortable and well furnished and there are many aids and adaptations related to sensory and other disabilities. There are three male service users living at number 2 whilst at number 10 there is a mixed gender group. The service users have diverse cultural backgrounds, which are reflected in the choice of decoration and furnishings. Both properties have rear gardens. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. The unannounced fieldwork visit was carried out over seven and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. The Assistant General Manager and the staff on duty were spoken to. Due to the communication difficulties of the service users they were not able to give their views of the home. Therefore observation of care practice was used to find out what their experiences of living at the home are. A tour of the premises took place. Care, staff and health and safety records were looked at. Two relatives were spoken with regarding their views of the service. What the service does well: Prospective new service users have the opportunity to visit the home and assessment is completed prior to moving in to ensure the home can meet their needs. People who live at the home take part in a variety of daytime activities including swimming, music, art, rock climbing, gym, canoeing, horse riding and rambling. Holidays for service users are being planned. Some service users have already been on holiday this year. Staff said that one service user went to Cyprus which he really enjoyed. Support is given by staff in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. It is good that care plans contain clear guidance for staff on how to offer choice to each service user. All care plans sampled included detailed information on the support required for personal care, for example support needed when bathing and preferences to include things such as the use of bubble bath. Where necessary the staff at the home seek advice from health and social care professionals. Staff actively promote contact with service users relatives. Two relatives spoken with were very happy with the care provided at the home. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 6 Bedrooms sampled were observed to be personalised according to individual needs, culture, gender and preferences. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. What has improved since the last inspection? What they could do better: The Registered Provider must ensure that where requirements are made these are addressed. Some requirements remain outstanding from previous inspections. Service users are supported to take responsible risks, but some work needs to be done on the ways in which risks are assessed and to ensure the assessment is up to date. Menu planning is currently done on an ad hoc basis. This needs to improve to ensure service users are provided with a healthy balanced diet. Staff need to ensure they follow service users meal time guidelines to ensure they are appropriately supported. The systems for the administration of medication require improvement to ensure service users medication needs are met. The home does have a training programme but this must improve to ensure staff receive all the training they need to enable them to meet service users needs. A plan to address some routine matters of maintenance is needed to ensure that the environment remains homely and meets service user needs. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 7 Grove Road has undergone several changes of Manager in recent years and a period of stability is required to ensure that the home has a clear sense of direction. 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. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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): 1, 2, 4, 5 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to admission to the home to ensure that their needs can be met by the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide available that contains information about the home as required in the regulations. The Service User Guide is a written document that contains pictures. Discussion with the Manager of House 10 indicates that she plans to further improve the document by adding photographs of the home. SENSE as an organisation is also working towards alternative formats to include audiotape and CD Rom. No new service users have moved to the home since the last inspection. However House 2 does have a vacancy and a prospective new service user has been identified. Discussion with the Assistant General Manager and staff indicates that relatives of the service user have visited the home and that a meeting to discuss possible admission was scheduled for the following day. Sampled records show that a full assessment had been completed involving the previous Manager of the home and Sense’s Admission and Referral Officer. At the previous inspection to the home in November 2005 the written contract for one service user who moved into the home in March 2005 was sampled. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 10 The contract was observed to relate to the Sense home where they previously lived and a requirement was made for the contract to be updated, this has not yet been done. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems are satisfactory and provide staff with the information they need to effectively support service users. Responsible risk taking is recognised as being important but needs to be improved in order to support care planning more effectively. EVIDENCE: Three service user care plans were sampled. Previous inspections have shown that care plans have not always been kept up to date. It was pleasing to see that the plans sampled had all been recently reviewed. They were detailed in content making it clear to staff how each service user needed to be supported. This included mobility, social and leisure, behaviour, daily living skills, family contact, communication, choice, privacy, dignity, rights, independence, fulfilment, cultural needs, health and self-care. Plans include information about individual’s likes and dislikes, things that are important to them, and are in a format that includes pictures and photographs. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 12 Evidence was available that other professionals are involved in the care of people who live at the home, for example the Speech and Language Therapist has completed assessments for eating and drinking. One service user has displayed changes to his usual behaviour. It was therefore good to see that this had been recognised by staff and that the Practice Development Worker had completed an assessment of behaviour and that advice on possible triggers had been obtained from the Behaviour Therapist. Each service user has a core team of staff, who aim to meet monthly, to monitor the care plan, progress on achievements, goals, health care and to action any points. Minutes of these core meetings were available in the file sampled but showed that for some service users meetings had not always occurred monthly. Sampled files did show that care plan review meetings are held annually with social workers and relatives invited to attend. Members of staff actively encourage each service user to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of objects of reference. It is good that care plans contains clear guidance for staff on how to offer choice to each service user. During the visit one service user had chosen to stay in bed all morning, this choice was respected by staff. Previous inspections have identified that development of risk assessment procedures was required to include the regular review of assessments. Progress has previously been slow, however at this inspection more progress was evident. Whilst further work is still required to ensure all service users have satisfactory up to date assessments for all areas of identified risk there had been many new assessments completed for each individual. Some manual handling assessments required review, one of these dated 2002 identified that the service user needed a bathing risk assessment, this still had not been done. Another service user had pulled the hair of a member of public whilst on an activity, an assessment of future possible risk had not been completed. Not all assessments are clear in identifying the level of risk but work to address this was observed to be in progress. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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, 14, 15, 16, 17 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Service users generally experience a good lifestyle but to ensure all service users receive a balanced and healthy diet planning of meals needs to improve. EVIDENCE: Opportunities for varied activities are provided. The care plans contained a “Schedule of activity”. Service users take part in a variety of daytime activities including swimming, music, art, rock climbing, gym, horse riding and rambling. This was also evidenced through daily records, photographs displayed and discussions with staff at the time of the visit. An activity was observed during the inspection. One service user was supported by an agency member of staff to undertake a music session, this was observed to be scheduled on his planner. It was good that lots of different instruments were available and that the staff was enthusiastic in her support. The service user was clearly enjoying the activity as he needed little prompting to participate. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 14 Two relatives spoken with said there was a good level of activities on offer. Service users participate in a variety of activities in the local community including shopping, walks, restaurants and pubs. During the visit service users who wanted to go out were supported to attend activities outside of the home, this included a visit to Woodgate Valley Country Park. Records did show that sometimes scheduled activities do not take place when there are no drivers on duty or when ratios of agency staff are too high, however this is not a frequent occurrence. Holidays for service users are being planned. Some service users have already been on holiday this year. Staff said that one service user went to Cyprus which he really enjoyed. Some service users have sensory lighting in their bedrooms, music systems, TV’s and videos. TV’s and music systems are also provided in communal areas. The home has a visitor’s policy and actively encourages visits from family and friends. There was evidence that relatives have contact by the telephone and letters /cards and are invited to review meetings. It is an area of good practice that SENSE employs a Family Liaison Officer, she had been involved with relatives in the process of the new admission to the home. Additionally, a family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. One member of staff has also had the opportunity to attend training on ‘Understanding and Communicating with Families’, organised by Sense. The standard of menu planning across the two houses was variable. House 10 have a weekly menu planned in advance whilst House 2 sometimes does a menu but not always. Discussion with staff also indicates that the menu is not always followed. Records of food are completed and show that generally service users do have a balanced and healthy diet although the service users in House 2 would benefit from having more fruit in their diet. Food stocks were observed in both houses. Both fridges were low on food stocks, House 2 also had low stocks of fresh vegetables, frozen and tinned foods. The visit occurred on a Wednesday, staff spoken with said that shopping was usually done on a Thursday or Friday. Shopping procedures need review to ensure stocks of food are available in line with the menu and in sufficient quantity’s to allow for service user choice. Meal time practice was observed in one of the houses. Food provided was pleasant in taste and service users were given good quantities. Staff generally gave support in line with the care plan but did leave two service users unattended whilst they were eating for a short period of time. The Manager will need to ensure that meal time practice is better managed in line with individual’s plan of care. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of how individuals’ are supported are in need of improvement. The systems for the administration of medication require improvement to ensure service users medication needs are safely met. EVIDENCE: All of the people living at the home require support in their personal care. Service users were all well dressed appropriately to their age, gender and the weather. All care plans sampled included detailed information on the support required for personal care, for example support needed when bathing and preferences to include things such as the use of bubble bath. Service users are supported to shop for personal toiletries and records show that service users are supported to wear make up or moisturiser in line with their preferences. As stated earlier in this report (Standard 9) some manual handling assessments need review and service users must be supported at meal times in line with their care plan (Standard 17). The health care for three service users was tracked. Files showed information relating to healthcare appointments including visits to clinics and specialist consultants. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 16 All individuals are registered with a local GP and detailed records are kept of all health appointments by the staff. Records sampled and discussion with the Manager evidenced that one individual who has diabetes receives support from staff and the Community Nurse to manage the condition. Records included regular visits to the dentist and optician. Sampled accident records and notifications sent by the home to the CSCI indicate a low level of accidents occur at the home. The medication administration system was sampled. None of the people who live at the home are able to manage their own medication. Medicines were seen to be stored appropriately. Eye drops were observed to have been dated on opening to ensure they can be disposed within 28 days. One medication was stored that had been dispensed in June 2005. This needs to be returned to the pharmacist and new stocks ordered. Such supplies should be held for a maximum of six months. The Manager must ensure that administration guidelines are clearly recorded and followed by staff. One medication that should be administered once a week by staff had been given twice one week and not at all another week. Controlled medication is appropriately stored but when administered needs to be recorded on the administration record as well as the controlled medication log. Work was seen to be in progress to update written protocols for ‘as required’ medication. Previous inspections have shown that not all staff have received medication training. Training records do not show that all staff that administer medication have completed suitable training. Discussion with the Manager and Assistant General Manager indicates there is some confusion as to what training staff have actually completed due to their previous college tutor leaving due to illness. Some staff received certificates and some did not. This needs to be clarified and training arranged for the staff that need it. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure. Adult protection systems need to improve to ensure service users are being protected from abuse and their welfare promoted. EVIDENCE: The service users due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. The homes complaints log indicated that no complaints had been received by the home. CSCI has not received any complaints since the last inspection. Sense’s policies and procedures for complaints have previously been observed to be satisfactory. Relatives spoken with said they felt confident that if they had any complaints they would be dealt with. The CSCI were notified by Sense of an allegation against a member of staff. Sense acted appropriately to ensure service users were protected and following investigation dismissed the member of staff. Clarification has been requested from Sense regarding referral of this matter to the Protection of Vulnerable Adults register. Training records showed that not all staff had received training in adult protection. The records of three staff were sampled, evidence of a Criminal Record Bureau (CRB) check being undertaken for one staff was not available. Records show Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 18 that the home seeks a profile of new agency staff, to include evidence of a CRB before they start work. Systems are in place to safeguard the monies of people living at the home. Receipts for expenditure were available and numbered. Staff count and check the balance of monies held at each handover. A record of personal possessions was available in the three service user files sampled. It is recommended that these are updated more frequently to ensure they accurately show the current possessions of service users and provide an accurate audit trail of any discarded items. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29, 30 The quality outcome in this area is adequate. Judgement has been made using available evidence including a visit to this service. The standard of the environment is variable with some matters of routine maintenance requiring attention. EVIDENCE: The two houses are in keeping with the local community. House 10 was observed to be more homely in style than house 2. Some issues of general maintenance were observed to be required. The kitchen in house 10 is worn and tatty in appearance. Plans will need to be put in place for its refurbishment. Several walls in House 10 were stained from drink splashes to include the dining room and will need repainting. Some blinds were missing at windows to include the conservatory and the bathroom. The bathroom blind was also missing at the last inspection and an action plan supplied by the previous manager of the home stated it had been replaced. The lounge carpet had two iron burn marks that were quite visible. The Practice Development Worker was able to evidence that he had recently completed an audit of the premises for House 2. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 20 It is good that the audit matched that of the Inspector and also that additional areas for improvement were identified. An audit for House 2 now needs to be done and a schedule of works completed. Bedrooms sampled were observed to be personalised according to individual needs, culture, gender and preferences. Some bedrooms have areas that are not fully accessible due to a sloping roof, this is not ideal where the individual has a visual impairment. The previous inspection identified some problems with odour control in House 2. Although there were no unpleasant odours at the time of the visit discussion with staff and reports from Sense show that odour control still remains an issue. The General Manager said that consideration was being given to installing new floor covering to assist in odour control. House 2 did not have supplies of hot water to the bath. The General Manager said this had been an ongoing problem for some weeks and that service users were having to have showers. Engineers have visited the home several times but left without having solved the problem. During the visit the General Manager contacted the landlords of the property who assured her that the problem would be resolved by the coming Friday. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. This includes objects of reference attached to doors so individuals know where they are in the home and bedrooms have appropriate systems installed to alert individuals to someone entering their room. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality outcome in this area is adequate. Judgement has been made using available evidence including a visit to this service. The current staffing arrangements in the home do not always ensure that service users are always supported and protected by appropriately trained staff. Historically there have been issues with high numbers of staff vacancies but at this inspection this appears to have been addressed. EVIDENCE: Support to service users is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Members of staff demonstrate that they have a good personal knowledge of the individuals in their care. Observation of the training matrix shows that 50 of the staff have achieved the standard of having an NVQ in care. The home has had some staffing difficulties of late due to staffing vacancies and some changes in service user behaviour that has increased the support they need from staff. Discussion with staff and the Assistant General Manger indicates that the staffing situation has now improved. Staff vacancies have now been reduced and one new member of staff was due to start work the following Monday, leaving one full time day post still to be recruited to. Having recognised that the previous staffing levels in House 2 were not always meeting the needs of service users an additional member of staff is working 9Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 22 30 am to 5-00 pm to provide three staff across the day. The Assistant General Manager explained that this shift is currently being covered by agency staff and is on a temporary basis until further assessment of service users behaviour has been completed. The files of three members of staff were sampled to establish if robust recruitment procedures are in place. For one new staff the file did not contain any evidence of a Criminal Bureau Check being undertaken, this was available in the other two files sampled. Satisfactory references were available in all the sampled files. Observation of the training matrix and discussion with staff and the General Manager indicates that staff do receive regular training but that further improvements are needed to ensure staff receive all the training they need to meet service user need. Still outstanding from previous inspections is training for some staff in diabetes and medication. Records also showed that several staff required adult protection and food hygiene training. Discussions with one newer member of staff indicated that he had not fully completed induction training but he was confident that it was being addressed by Sense. One member of staff who had transferred from another Sense home had not completed an induction to Grove Road. Induction is needed to ensure transferring staff are familiar with the needs of service users and the home’s policies and procedures such as the fire procedure. Evidence shows that staff are appropriately supported and receive regular supervision. Sampled staff files and a supervision planner shows that the standard of at least six supervisions a month is being met. Regular staff meetings are held. It is good that a team building day for staff has also been arranged. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not had a registered manager in post for some time, the home has therefore not benefited from a clear sense of direction. Systems are in place to promote the health and safety of service users but some updating of risk assessments still needs to be done. EVIDENCE: The Manager has recently ceased employment at the home. Discussion with the Assistant General Manager indicates that she is concerned that the action plan completed by the previous manager in response to the last CSCI inspection and were not accurate. She is now putting systems in place to ensure previous requirements are actioned. The Assistant General Manager (AGM) is currently working at the home to provide management cover, supported by an unregistered manager based in House 2. Discussion with staff and the AGM indicates that initially the AGM was finding it hard to provide adequate management support, as she was still responsible for Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 24 overseeing other care homes and was not able to designate adequate time to working at Grove Road. Staff spoken with did however hold the view that in recent days the AGM had been able to devote more time to Grove Road and this was backed up by the staff rota. Following the inspection the inspector telephoned the home several times attempting to speak with the AGM but was unsuccessful as she was away from the home at various meetings. The AGM must ensure she devotes adequate management time to the home. Grove Road has undergone several changes of Manager in recent years and a period of stability is required to ensure that the home has a clear sense of direction. Systems are in place to assure quality. This includes monthly visits to the home by a general manager who completes a report and forwards this to the CSCI. Audits are carried out periodically to include the staff files by personnel and financial audits. A self assessment audit for house 10 was completed in August 2005. This included outcomes of CSCI inspections, questionnaires from staff and relatives and an action plan to address issues identified. Health and safety at the home was generally well managed. The home has a range of policies, procedures and systems in place to comply with the requirements of health and safety legislation all of which are made known to staff both verbally and in written form as part of their induction. However as stated earlier in this report further work to develop the risk assessment system is required. The West Midlands Fire Officer has conducted a visit to the home. It was recommended that the fire alarms for the houses are separated as the alarms sound in both houses if activated, even though the houses are on opposite sides of the close. Discussion with the Area Manager indicates that an order has gone in for this work to be done and will soon be completed. The fire safety records were examined and all tests, checks, servicing of equipment and drills had been completed or scheduled as appropriate. The safety certificate for the homes hard wiring dated October 2000 recorded that it should be retested in five years time, this was therefore overdue. The Assistant General Manager contacted the landlords of the property when this was brought to her attention and arranged for it to be done. Staff test the fridge and freezer temperatures regularly to make sure that food is being stored at the correct temperature. Staff test water temperatures weekly. Records of these showed that these are safe. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 1 X 3 X X 2 X Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 26 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. Standard YA5 Regulation 5(1) Requirement Timescale for action 30/08/06 2. YA42 YA9 13(4) 3. YA17 16(2)(i) A copy of a written contract / statement of terms and conditions, detailing the required information needs to be available in the home. In needs to specify the room to be occupied, fees, term and conditions, facilities and support. Service user or their representative should sign it if possible. Outstanding requirement from 31/10/04. (Current contract was not available for one service user). The Manager must ensure all 30/06/06 risks to service users are identified and a risk assessment completed and reviewed at least six monthly. Assessments must be clear in detailing the level of risk and control measures in place. Menu planning must be reviewed 30/05/06 to ensure service users receive a balanced and healthy diet. Adequate supplies of food must be available at all times to enable service users to have a choice of meals. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 27 4. 5. YA17 YA20 16(2)(i) 13(2) 6. YA20 YA35 13(2) 18(1) 7. YA20 13(2) 8. YA20 13(2) 9. 10. YA35 YA23 YA24 13(6) 18(1) 23(2)(b) 11. YA27 12(4) 23(2) Staff must provide meal time support to service users in line with individual care plans. Medication stocks should be retained for no longer than six months after the date of dispensing. Outstanding requirement from 30/11/05. The confusion over which staff have completed medication training must be addressed. Training records must clearly show who has completed this training. Training must then be arranged for any staff who require it. The Manager must ensure that medication administration guidelines are clearly recorded on the medication administration record and are followed by staff. Staff must sign the medication administration record when medication is given to service users, to include controlled medication. Ensure all staff have received training in protection of vulnerable adults. A planned schedule for maintenance works must be completed to include: - Repainting of stained walls in House 2 - Refurbishment of kitchen in House 10 - Replace missing conservatory blinds in House 2 - Replace lounge carpet in House 2. Ensure that suitable window coverings are provided in bathrooms to ensure the privacy and dignity of service users is protected. Outstanding from 30/11/05. 30/05/06 30/05/06 30/06/06 30/05/06 30/05/06 30/06/06 30/06/06 30/05/06 Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 28 12. 13. YA30 YA34 YA23 YA35 23(2) 19 Sch 2 18(1)(c) 14. Ensure the premises are kept 30/05/06 free from offensive odours. Outstanding from 30/11/05. Ensure staff recruitment records 30/06/06 contain all information as specified in Schedule 2 to include evidence of CRB check. The Manager and Registered 30/07/06 Provider must ensure that staff are suitably skilled by ensuring appropriate training is provided. Training in supporting people with diabetes should form part of the core programme for this house. Outstanding from 30/12/05. Staff new to the home must complete a satisfactory induction with a record of this available. A permanent manager must be recruited and an application for registration made to the CSCI. An up to date safety certificate is required for the home’s electrical hard wiring installation. 15. 16. 17. YA35 YA37 YA42 18(1)(c) 10 23(2)(b) 30/06/06 30/07/06 30/06/06 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 YA23 Good Practice Recommendations It is recommended that service users inventory of personal possessions are updated more frequently to ensure they accurately show the current possessions of service users and provide an accurate audit trail of any discarded items. Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 29 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 Grove Road, 2 & 10 DS0000016795.V290967.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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