Inspection on 04/05/07 for 2 & 10 Grove Road

This inspection was carried out on 4th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 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 26/04/06

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 Julie Preston Unannounced Inspection 4 & 10th May 2007 11:00 th Grove Road, 2 & 10 DS0000016795.V335799.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 Grove Road, 2 & 10 DS0000016795.V335799.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. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Grove Road, 2 & 10 Address Kings Heath Birmingham West Midlands B14 6ST 0121 441 2414/3221 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association ****Post Vacant**** Care Home 8 Category(ies) of Learning disability (8), Sensory impairment (8) registration, with number of places Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 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 26th April 2006 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 four 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. Information is shared with service users by use of objects of reference to enable individuals to make choices and map out their location within the home. Fees charged to service users range from £7000 to £10000 a month, to which individuals pay a set amount from their Department of Works and Pensions benefit. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key fieldwork took place over nine hours. The inspector talked to the manager and staff about the way they care for service users and help them stay safe. Service users do not talk, instead they use objects to make choices, so the inspector watched how staff help them choose things to do. Records that tell you how service users are cared for were looked at as well as records that tell you how staff have been trained to care for service users. The rooms in the home were looked at to make sure they are comfortable and clean. What the service does well: What has improved since the last inspection? Plans that explain how to care for service users are better written so that people’s needs are understood and met. There is more choice of healthy food and service users have help to eat their meals. Staff have had training to help them understand how to protect service users from harm and understand their health. There is some new furniture, which makes the home more comfortable. There is a new manager, who is working with the staff to make things better and safer in the home. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 7 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.V335799.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully assessed prior to admission to the home to ensure that their needs can be met within the service provided. EVIDENCE: One service user has been admitted to Grove Road since the last inspection and this person’s records were looked at to establish how the home had arranged the person’s admission. SENSE provide an admissions officer, who provides the central point of contact for placing officers referring potential service users to the home. The manager explained that meetings took place to discuss the plan to assess service users referred to establish that the home could meet their needs. The records sampled showed that a thorough assessment procedure had been followed, incorporating information from social workers, the person’s family members, Speech and Language Therapists and that of work done by staff in the home. It was considered positive that staff had visited the service user in a variety of settings, including the day centre and the family home to observe the person Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 9 and gather further information to assess need. Trial visits had been offered and the person’s responses to the visits recorded prior to admission. Records of reviews were observed, which indicated that the placement was being monitored to ensure that the person’s needs continued to be met within the home. Grove Road, 2 & 10 DS0000016795.V335799.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): 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 planning systems are satisfactory and provide staff with the information they need to effectively support and care for service users. Risk management systems do not adequately ensure that service users needs are consistently met. EVIDENCE: Four service users care plans were sampled. All were clearly written, explaining the person’s needs and preferred routines to enable staff to provide consistent support and care to service users. The five members of staff spoken to during this visit demonstrated good knowledge of individual’s needs, which reflected the information within the care plans sampled. Observation of staff supporting service users at lunchtime and with activities indicated that people’s independence is being promoted. For example, staff Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 11 offered hand over hand assistance with meals so that “feeding” people was avoided, which could reduce individual’s skills and create more dependence. The quantity of paperwork contained in care plan files made it difficult for a new reader to sift out historical information from current information. Care plan files that contain accurate and up to date information about service users needs would enable staff to provide consistent care that is reflective of individuals’ needs and preferences. Each service user has a core team of support staff that meet on a regular basis, to discuss the effectiveness of the person’s care plan and consider action needed to improve the person’s quality of life. The records sampled showed that service users had been supported to learn new skills, such as making hot drinks and using new objects of reference to make choices about activities. Risk assessments that describe the controls in place to manage identified hazards and maintain service users independence and safety were sampled in house 10. All were noted to be in need of review to make sure they remain relevant to service users needs. One assessment identified a need to make a referral to Occupational Therapy for input in supporting a service user to access bathing facilities safely. It was not clear that this had been done, which could leave the person at risk of harm. All service users living at Grove Road need support to manage their finances. The records of income and expenditure were observed for two service users to establish how they are protected by the home’s systems. The manager explained that individual records are audited on a regular basis, both by senior staff in the home and by a SENSE representative. The records sampled at this visit showed no anomalies, which indicated that money is being well managed for service users protection. Receipts are kept of expenditure and those sampled matched the records observed. Grove Road, 2 & 10 DS0000016795.V335799.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: Service users living at Grove Road have a visual impairment and therefore much emphasis is placed upon activities that involve tactile and sound/aural (where this is appropriate as some service users have a hearing impairment) engagement. Objects of reference are used to assist service users in decision-making and to share information. A member of staff was observed to support a service user to handle a shoe to indicate the option of going out for a walk. Staff in house 2 wear individual bracelets every day to enable service users to recognise who they are and understand who is in the home. Matching bracelets are mounted on the wall in the hallway to correspond with the staff on duty each day. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 13 Wind chimes hang outside the front door of house 2 to alert service users that they are home. A wide range of musical instruments are available for service users, which were well used at this visit, indicating that service users enjoy this activity. Some service users have ipods to listen to music without disturbing others and both houses have a variety of tactile markers (significant objects mounted on doors) to enable service users to determine the room they are entering. The care plans sampled showed that service users activity preferences had been assessed and recorded. Observation of daily records and practice at this visit confirmed that service users were offered opportunities to take part in things they enjoy such as visiting places of interest, shopping for personal items, going for pub lunches, cafes and listening to and creating music. Staff at the home commented on the ways in which they support service users with daily activities and routines. The five staff members spoken to were aware of the need to offer age appropriate assistance whilst out with service users, offering an arm to hold when walking rather than holding hands. All staff referred to the need to respond to service users physically moving them as an indication of the person wanting something or needing space alone. The manager explained that she marked the occasion of Christmas Day by offering service users chocolate first thing in the morning to identify the day as a special one. Holidays for service users are currently being planned. SENSE provides £300 funding towards holidays each year. A member of staff advised that a service user was going to Snowdonia for a long weekend. Staff had visited the site and conducted a risk assessment of the facilities; changing the proposed location as it was not suitable for a person with a visual impairment. The service user had taken part in practice walking sessions at the Clent and Malvern Hills in the run up to the holiday. Observation of financial and daily records evidenced that the service user had been out shopping for the equipment needed for the trip, which was being stored in his bedroom as a reminder that the holiday was imminent. The home has a visitor’s policy and the manager commented that relatives have regular contact either by telephone, email or in person. Recently, a barbeque took place to which relatives were invited. The daily records sampled described service users enjoyment of this event. Menus and records of food consumed by service users were sampled in both houses to establish that a balanced and varied diet is provided that meets individuals’ needs and preferences. A range of food had been offered including Sunday roasts, curries with rice and low sugar meals, which is reflective of service users cultural and healthcare needs. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 14 At lunchtime, staff offered sensitive support to individuals that require assistance with eating to promote both their dignity and independence. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users personal care needs are well managed and their privacy and dignity is respected. Healthcare and medication records do not demonstrate that service users needs are being fully met so that they maintain good health. EVIDENCE: Sampled care plans contained detailed information about service users’ personal care needs and their routines, such as whether a bath or shower is preferred and the need to provide care in private to promote the person’s dignity. Staff described the practice of providing same gender care as a means of further promoting dignity and talked with confidence about the support they offer to individuals, which was consistent with the care plans sampled. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 16 Financial and daily records showed that service users shop for their own toiletries and clothes and use local hairdressers and barbers as part of their regular routines. The health care records for four service users were tracked. Files showed that some information relating to health appointments had not been recorded. For example, a service user that needed six weekly chiropody did not appear to have received this service since February 2007, prior to that date the last entry was 2005. Within the same file, the person’s attendance at diabetic clinic had not been recorded since 2005, despite the Health Action Plan (a plan describing how to support the person to maintain good health) stating the need for regular visits. This does not indicate that service users health care needs are being fully met. This report has identified that a referral for Occupational Therapy required by a service user may not have been followed up, which again could lead to individual’s needs being unmet. The system of storing, administering and recording medicines kept in the home was looked at to establish that service users are protected by robust procedures. Medication was observed to be securely stored in a locked cabinet and it was considered positive that staff had received training in the safe handling of medicines to further safeguard service users health and well being. The administration records sampled included information about how to offer service users their medication, for example, with a glass of water and what to do if medicines were refused. Some controlled drugs are required by service users, which were securely stored. A sample audit of the controlled drugs register, medication administration record and stock on site showed that the medicine had been given to service users according to the prescribed instructions. Two issues were identified for improvement to ensure that service users receive their medicines safely. In one case a code had been entered on a medication record, which gave no explanation of what had occurred and there was no definition of the meaning of the code. Secondly, there was no written protocol for administering a service user’s tablets, which means that the person may not receive the medication as required. Some staff spoken to were not clear of the circumstances under which this medicine should be given. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for service users representatives to make complaints about the service are satisfactory so that they can be confident their views will be listened to. Service users are safeguarded by the home’s adult protection procedures. EVIDENCE: The communication needs of service users living at Grove Road means that they are not able to raise complaints about the home and are reliant on relatives or staff to do so on their behalf. From conversation with staff members it was evident that they were alert to recognising changes in individual’s behaviour as an indication of dissatisfaction and described using several approaches such as giving the person space or engaging them in an activity in response. The manager stated that parents and relatives are provided with a copy of the home’s complaints procedure. The complaints log showed that none had been received within the last twelve months. Questionnaires are also sent to parents and relatives inviting their comments on the running of the home, which were noted to be positive. The CSCI have received no complaints about the home in the last twelve months. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 18 Since the last inspection, staff have received training in adult protection. One member of staff commented that the training had helped her consider more “hidden forms of abuse like financial, so that I’m really careful about accurate record keeping”. The five staff members spoken to by the inspector said they would always report any suspicion of abuse so that service users were protected. Systems are in place to safeguard the monies of people living in the home. Staff were observed to check financial records at the shift handover. Within the staff files sampled, all contained confirmation that a satisfactory Criminal Records Bureau check had been received prior to the person’s employment, for the protection of service users. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Outstanding repairs and maintenance impact on service users comfort and health and safety within the home. EVIDENCE: 2 and 10 Grove Road are situated close to the area of Kings Heath, where there are a range of shops, pubs and places of worship within walking distance. This is important to the service user group, who enjoy these activities. Improvements to the premises since the last inspection included the replacement of the lounge carpet in house 2, as the previous one had been worn and stained, new blinds in bathrooms to promote service users dignity and new sofas in house 2 for service users comfort. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 20 Both houses were warm, clean and free from unpleasant odour, which had been raised as an area of concern at the last visit. Shared space in the lounges and dining rooms were free from clutter that could create difficulties for people with a visual impairment, whilst moving around. It was therefore disappointing that the garden in house 2 restricted service users access due to its layout. The garden has gravel pathways, which create an uneven terrain that is further aggravated by loose rope handrails that do not allow sufficient support to anyone using them for guidance. Raised slabs to the garden swing create a trip hazard, which means that service users are dependent on staff to escort them to the garden, thus impacting on their independence. A large part of the garden is inaccessible as it is covered with bluebells that is reportedly subject to a preservation order and therefore cannot be removed. The manager and staff team expressed their concern about the unsuitability of the garden for the service user group that live at the home and are attempting to resolve the situation with the Housing Association that own the premises. In contrast, the garden in house 10 was accessible, with level surfaces and raised beds to enable service users to touch and smell flowers planted there. Some maintenance issues were identified that impact on service users comfort, health and safety. In house 2, the porcelain cistern lid had been removed from the toilet by workmen to fit a new cistern and had not been secured on completion of the work. This was considered hazardous to service users, who may lean on the lid and risk injury if it fell. A staff member reported this as a matter of urgency to the Housing Association, but no action had been taken to secure the lid six days later. The bath in this room was also in need of repair. The bath panel was loose and falling away form the bath and the grout around the tiles was dirty and mould stained, which does not create a pleasant environment for service users to bathe. In house 10, the sofa and two easy chairs were damaged meaning that anyone sitting down sat on loose springs, which is not comfortable. The carpet in the lounge in house 10 was stained and marked in two places by iron burns and is in need of replacement. The kitchen units in house 10 were observed to be stained, worn and damaged. No progress had been made following requirements at the previous inspection to refurbish this area. Laundry facilities are situated away from food preparation areas so that the risk of food contamination is reduced. Industrial washing machines with a sluice cycle are provided in keeping with service users needs. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by robust recruitment and selection procedures and benefit from the support of a well trained team of staff so that their individual and collective needs are met. EVIDENCE: From observation of staff interaction with service users it was evident that service users were comfortable in their presence and sought them out frequently throughout this visit. Staff responded well to being prompted by service users. For example one person made it clear that she wished to have some music on, which staff quickly assisted her to do. The staff rota sampled showed that both male and female staff are employed, which is consistent with the gender of the service user group and that sufficient staff are on duty each day to meet service users needs. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 22 The recruitment records of the most recently appointed member of staff were sampled. Evidence was seen that appropriate checks had been made prior to the person’s employment to demonstrate their suitability to work in the home and for the ongoing protection of service users. Observation of the records and discussion with the manager showed that care is taken to select staff using a range of techniques in addition to submitting an application form and having an interview. The prospective employee watches a role-play as part of the recruitment process and is asked to comment on good and poor practice and also fills in a sample diary to enable the interviewers to form an opinion of their report writing skills. The manager stated that she believed this was of benefit to service users and assisted her to consider employees future training needs. Staff training records sampled showed that a range of opportunities are available in addition to mandatory health, safety and protection training. Staff have received training that is specific to service users needs such as deafblind awareness, diabetes care and managing challenging behaviour. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the home is improving for the ongoing protection of service users. Further attention to the management of health and safety practice will lead to a safer environment for service users. EVIDENCE: The home’s manager has been in post since November 2006. The manager confirmed her commitment to submitting an application for registration to the CSCI. The manager has completed NVQ Level IV in care and her Registered Manager Award as well as achieving a BSc in Psychology and several courses in management strategies. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 24 Staff present at this visit commented on the manager’s openness and considered that service users had received a better standard of living since her appointment. Two staff stated that they were very pleased to have been given some extra responsibilities by the manager to aid their professional development. SENSE have a Policy and Quality Team who have developed and implemented questionnaires for stakeholders such as relatives and purchasers, inviting their comments on the running of the home and the promotion of service users choice, privacy, dignity and independence. The culmination of this work will be analysis of the information received which is fed back to the manager and staff, who must submit an action plan based on the feedback to demonstrate ongoing benefit to service users. Health and safety is generally well managed within the home. There are a range of policies and procedures in place that describe the way health and safety is managed within the home. Some of these were observed and it was noted that they had been made available to staff as part of their induction. Staff test the hot water each week to make sure that it is delivered at a safe temperature (on or close to 43 degrees Celsius). The records in house 10 for the period 7th May – 10th May showed readings of 50 degrees Celsius in a hand basin, which had not been followed up to reduce the risk of service users being scalded by hot water. Records of the tests to make sure the fire alarm is working in house 10 had identified a problem each week with a fire door since December 2006. The records stated that when the alarm was set off the fire door would not close properly. A member of staff had reported this fault on 8th May 2007, however it remains of concern that no action was taken between December and May, which could have placed people in the home at risk of harm. Fire drills had not been conducted on a regular basis in house 10 to enable staff and service users to practice evacuation in the event of an emergency; the last record was in August 2006. It was noted that the laundry door in house 2 (a fire exit) was secured with both bolts and a locking device that required a key. This means that in the event of an emergency the fire door may not be easily accessible, which could prove a hazard to people in the home. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 3 X X 2 X Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 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 YA9 Regulation 13(4) Requirement Risks to service users must be identified and a risk assessment completed, which is subject to regular review so that individuals are supported to take responsible risks and maintain their personal safety. Not met from previous inspection on 26/04/06. Service users must receive health care according to their individual needs and their records completed to ensure that adequate healthcare monitoring takes place. Protocols must be written and implemented for service users that require PRN medicines, so that they receive medication according to their individual needs. Codes entered onto service users medication records must be explained in writing so that the record clearly demonstrates whether the service user has received their medication, or that other action has been taken in response to circumstances DS0000016795.V335799.R01.S.doc Timescale for action 24/06/07 2 YA19 13(1)(b) 17(1)(a) 24/06/07 3 YA20 13(2) 01/06/07 4 YA20 13(2) 01/06/07 Grove Road, 2 & 10 Version 5.2 Page 27 5 YA24 23(2)(o) 6 YA24 13(4)(c) 23(2)(c) 7 YA24 13(4)(c) 23(2)(c) 8 YA24 23(2)(c) 9 10 YA24 YA24 23(2)(c) 23(2)(c) where medication has not been given. The garden in house 2 must be made accessible to service users so that they are not placed at risk of harm whilst using the facility. The cistern lid in the bathroom of house 2 must be made safe so that service users are not at risk of harm when using the bathroom. The bath panels in house 2 must be repaired and the tiles cleansed thoroughly to ensure that service users have safe and comfortable bathroom. The sofas and easy chairs in house 10 must be replaced so that service users have adequate, comfortable seating. The lounge carpet in house 10 must be replaced. The kitchen in house 10 must be refurbished. Not met from previous inspection on 26/04/07. Hot water must be delivered at temperatures that do not pose a scalding risk to service users. The fire door in house 10 must be repaired to ensure that it closes when the fire alarm is activated for the protection of people in the home. Fire drills must be conducted on a regular basis to enable people living and working in the home to practice evacuation. Advice must be sought from fire safety professionals with regard to the suitability of the locking device on the laundry door to ensure that it does not impair the safe evacuation of people in the home in the event of an emergency. DS0000016795.V335799.R01.S.doc 01/09/07 12/05/07 01/06/07 01/06/07 24/06/07 01/09/07 11 12 YA42 YA42 13(4)(c) 23(4)(c) 12/05/07 24/05/07 13 YA42 23(4)(c) 01/06/07 14 YA42 23(4)(b) 01/06/07 Grove Road, 2 & 10 Version 5.2 Page 28 Action must be taken in accordance with the advice given. 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 YA37 Good Practice Recommendations Service users care plan files should be “thinned out” to remove historical information and leave that which is relevant to individuals’ current needs. An application for the registration of the new manager should be sent to the CSCI. Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 29 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 Grove Road, 2 & 10 DS0000016795.V335799.R01.S.doc Version 5.2 Page 30 - 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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