Inspection on 16/05/07 for Hagley Road

This inspection was carried out on 16th 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hagley Road 16/09/09

Hagley Road 23/09/08

Hagley Road 30/04/08

Hagley Road 17/10/06

Hagley Road 26/01/06

Hagley Road 16/09/05

Hagley Road 07/01/05

Hagley Road 20/05/04

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

CARE HOME ADULTS 18-65 Hagley Road 429 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Sarah Bennett Key Unannounced Inspection 16th May 2007 10:00 Hagley Road DS0000016865.V335224.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 Hagley Road DS0000016865.V335224.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. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hagley Road Address 429 Hagley Road Edgbaston Birmingham West Midlands B17 8BL 0121 420 2970 0121 420 2970 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) Mind in Birmingham Vacant- Phillip Glenholmes (Acting Manager) Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may provide care for ten Service Users with a mental disorder (MD excluding learning disabilities or dementia) under the age of 65. That a named service user who is over 65 years of age can be accommodated and cared for in this Home. 17th October 2006 Date of last inspection Brief Description of the Service: 429 Hagley Road is situated on a busy main road close to Bearwood. The building is of a traditional appearance and large proportions in keeping with other properties in the area. There are no external indicators to emphasise the function and purpose of the home, it blends in well with the other residential houses. Close to the home is a shopping centre, pubs, restaurants and leisure facilities. The area is also well served by a range of transport systems. The homes brochure states that: ‘The home provides long term care for people suffering with mental health problems’. The homes philosophy gears towards a slow track rehabilitation with residents being allowed time to develop and enhance any skills they have using statutory and non-statutory services. The home allows clients to fulfil their potential and future goals in terms of their accommodation. The fees at the home are £488.38 per week. A copy of the last inspection report is available in the home for visitors to read if they wish to. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork taking place a range of information was gathered that included notifications received from the home. One inspector carried out the unannounced fieldwork visit over seven hours. This was the homes key inspection for the inspection year 2007 – 08. Five of the people living in the home, the staff on duty, the Manager and the Operations Manager were spoken to. Time was spent observing care practices, interactions and support from staff. A tour of the communal areas of the home took place. Care, staff and health and safety records were looked at. Since the last inspection in October 2006 there had been one anonymous complaint made to the CSCI regarding several areas of the management of the home. This was investigated as part of this visit and it was found that no regulations had been breached. Further details of this complaint are detailed in the ‘Concerns, Complaints and Protection’ section of this report. What the service does well: What has improved since the last inspection? Care plans are regularly reviewed and identified how individuals are supported to achieve their goals. This means that staff know what support each person needs and staff are aware if people’s needs change. There is a menu and this is often updated to include the likes and dislikes of people living in the home so they can choose what they eat. Each person has a copy of the complaints procedure so if they are unhappy with anything they know what they need to do to make a complaint. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 6 Some staff are now doing accredited training in the safe handling of medicines so they know what the medicines they give to people are for and how to give them in the right way. Some areas of the home had been redecorated and the home was clean making it a more comfortable place to live. People living in the home are often asked what they want to do, where they want to go and how the home should be run so they can make choices about their day-to-day lives. Hazardous substances were locked away so ensuring that people could not harm themselves by using them inappropriately. A lot of work had been done to help the staff and the people who live there adjust to the new management style in the home. This was continuing so that there is not tension between staff, which could make it an unhappy place to live. What they could do better: Risk assessments need to be in place so the risks of people smoking in their bedrooms are reduced as much as possible to ensure their safety and well being. The lock on the medication fridge must be repaired or replaced. This will ensure that the medication cannot be taken and used inappropriately which could cause harm to the people living in the home. The premises must be maintained to ensure a well-maintained and homely environment for the people living there. All locks on bathroom and toilet doors must be working to ensure the privacy of people living in the home. Staff must receive the training identified so they have the skills and knowledge to meet the needs of the people living in the home. An application for registration of the manager must be forwarded to the CSCI to ensure that the home is well run for the people who live there. Hot water outlets in the home must be assessed for the risk they present to the people living in the home and action taken to minimise any identified risk. Action must be taken to ensure that an electrician tests the electrical wiring of the home every five years so that it is safe. Hagley Road DS0000016865.V335224.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. Hagley Road DS0000016865.V335224.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 Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have the up to date information about the home so they can make an informed choice about whether or not they want to live there. Each person living in the home has a licence agreement with Focus that states the terms and conditions of their stay so they know what their rights and responsibilities are. EVIDENCE: The service users guide to the home generally included the relevant and required information so that a prospective service user could make a choice about whether or not they want to live there or their needs can be met there. However, the information about the management and staffing arrangements was out of date and needs to be updated. There had been no new people admitted to the home since the last inspection. Therefore, the standard relating to assessment was not assessed at this visit. Records sampled of the people who live in the home included individual licence agreements with Focus. These stated the terms and conditions of the persons Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 10 stay at the home so they are aware of what their rights and responsibilities are whilst living there. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person has a care plan so that staff know how to support them to meet their needs and achieve their goals. The people living in the home are supported to make decisions about their day-to-day lives and the running of the home. Arrangements for taking risks are not sufficient to ensure that people receive appropriate support to ensure their health and well being. EVIDENCE: Two records of the people living at the home were sampled. These included an Essential Lifestyle Plan that had been developed by the individual and their key worker. It included positive reputation, what is essential for me, what is important to me, what I prefer/ enjoy doing and my daily routine. Each month the person’s key worker writes a monthly summary based on their plan. This includes how the person’s mental health, physical health, interpersonal skills Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 12 and domestic skills are, if further support is needed or the support needs to be offered in a different way. The Manager had introduced a care planning system that was person centred and this is to be used with all the people living there. It included a section on how to be successful in supporting the individual and was very detailed. Care plans had been reviewed with the person’s Community Psychiatric Nurse (CPN) or social worker where there was one allocated to them. Some people who have lived at the home for a number of years do not have an allocated CPN or social worker. There were two meetings of the people who live in the home in April. People talked about day trips they would like to go on, the Easter party they had that was a success, organising a social evening, designated smoking areas and the new summer menu. They chose colours for the bathrooms to be painted. They agreed that DVD’s could be watched in the lounge between 2-4pm so as not to disturb others evening programmes. Meetings have only started to take place regularly since February this year, before that there were no minutes of meetings since 2005. The manager said that they did have meetings with the people living in the home every week. Some people said this was too often so they are going to put the frequency of the meetings to a vote at the next meeting. Records showed that where a person did not like working with their key worker their key worker had changed so this was a positive relationship for the individual. Records sampled included individual risk assessments. These stated how staff are to support the person to minimise the risks of non-payment of their rent, self-harm, giving their money away to strangers, isolation, bullying, their behaviour, using the stairs and a fire starting. Some of the risk assessments had not been reviewed since 2005 so it was not clear whether people were being given the right support to minimise these risks. One person’s records indicated that the support given to minimise the risks when they are on holiday had changed but their risk assessment was not updated to reflect this. Where an individual’s behaviour had changed and the risks posed by this had increased staff had contacted the person’s social worker and arranged a review to discuss this and ensure that the risks were being managed to prevent harm to the person and to others. People who smoke can do so in their bedrooms and ashtrays are provided. At the last inspection it was required that for each person who smokes in their bedroom a risk assessment stating how the risks are to be reduced must be in place. These have not yet been completed. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the people living in the home experience a meaningful lifestyle. A varied and healthy diet is offered and people choose what they eat. EVIDENCE: Records sampled showed that people go shopping, to the pub, the library, the post office to collect their money, go for bus rides, enjoy reading, watch TV and read magazines. Staff said and records showed that one person asks most days if any shopping is needed and will then go to local shops to get it. Staff made sure that money was available so this person could go shopping when they wanted to as they said they wanted to go soon so they did not get caught in the rain. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 14 One person had just returned from a long weekend on the Isle of Wight with a member of staff and said that they had a good time. Some people said they did not like going away on holiday but prefer to go on day trips. Staff said that the people living in the home were talking at their last meeting about wanting to go out for a day to Weston and the Manager had agreed to arrange this. Staff said that recently one person has started going out more with staff and is spending less time on their own in their bedroom so is less isolated. One person said they enjoy going to college where they study Communication Skills and IT. They were proud of their achievements on these courses for which they had received certificates. One person who was a football fan had photographs and pictures of their team all around their bedroom. They are a member of their teams programme club and have these sent to them during the football season. They said that they go to matches when their team are playing in the Midlands. Records showed and people said that they are supported to keep in contact with their family and friends by visits and phone calls. One couple have shared their bedroom for many years so helping to maintain their relationship. Records showed and people said that they do the washing up, clean their bedrooms and do their own laundry. Where it is safe for individuals they have their own kettle and fridge in their bedroom so they can make their own drinks when they want to. A record of what each person living in the home eats is kept to ensure that people are receiving a healthy and varied diet that meets their cultural and religious needs where appropriate. Food records sampled showed that a varied and healthy diet is offered and a choice of food is offered. The food records reflected the cultural background of the people who live there. Several records showed that people refused to eat, although this was often at breakfast or lunchtime and they generally had a main meal each day that was varied and healthy. The reason for their refusal is more likely to be a symptom of their illness rather than not liking what food was available. The fridge, freezer and food cupboards were well stocked and fresh fruit and vegetables were available. One person goes out shopping each day to the local shops to get any fresh food needed for that day. Shopping is done in local shops and supermarkets so that people living in the home have an opportunity to choose what food they want to buy whilst accessing the community. Each week a takeaway is purchased for a main meal, which is the choice of the people living there. This is paid for out of the home’s food budget. People living in the home said that they like the food and are encouraged to make their own lunch or breakfast. They said there is plenty of food available and if there is something they want they can have money from petty cash and go and buy it. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 15 Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 16 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. The personal and health needs of individual’s are met so ensuring their well being. Arrangements are not sufficient to ensure that the management of the medication protects the people living in the home. EVIDENCE: Records sampled showed that support and encouragement is given to individuals as appropriate to help them to maintain their personal hygiene so improving their self-esteem. Staff said that recently one person’s personal hygiene had improved, they now had a shower every day and this had improved their general well being. Records sampled showed that people had regular health checks including going to the dentist and optician. Each person is registered with a local GP and records sampled showed that when a person had a health need they were supported appropriately to visit their GP. Records showed that advice given from the GP to individuals was followed. Staff ensured that people attended Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 17 any follow-up appointments to ensure that the person’s health needs were met. The current medication is stored in a locked cabinet that is secured to the wall. The Manager said that medication arrives from the pharmacist three days before it is due and this is kept in a locked cupboard in the office to keep it safe when it is delivered. Some medication is kept in the fridge but the lock on this was broken. The Manager said he had made enquiries about getting this repaired, which was proving difficult and quotes to replace it had been very expensive. In the interim the office door is locked when there are no staff in there to help to minimise the risk of people coming in and using the medication inappropriately. The Medication Administration Records (MARS) could be confusing as there is not a running total of the medication on it so it is not easy to audit if medication had been given appropriately. It is handwritten and not printed by the pharmacist so there could potentially be errors made in recording. The Operations Manager said that MIND made a decision to use their own MARS, as they use a variety of different pharmacists and some medication is received from the CPN (Community Psychiatric Nurse). They said that this had been agreed with the CSCI pharmacy inspector for this reason. It should be clearer about what medication is received, when it is received and give a running total as medication is given. The Manager said this would be discussed at the next staff meeting and it would be decided how they are going to do this. Staff had appropriately signed the MARS sampled. Each person had a medication support plan so that staff know what medication the person has and what support they need to take it. Where people are able to they administer their own medication and staff give them their pack each week. There were no controlled drugs (CD’s) prescribed for those living in the home. However, there was a CD register and cabinet in place if needed in the future to ensure they are stored and administered in accordance with pharmaceutical guidelines. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 18 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. Arrangements are in place so the views of people living in the home are listened to and acted on. The people living in the home are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure included the relevant information so that people would know how to make a complaint and how this would be investigated. Records sampled included a copy of a letter from the Manager to one of the people living in the home in response to a complaint they made about another person living at the home. The letter stated that the complaint was upheld and appropriate action had been taken. This showed that people’s views are listened to and action is taken to ensure that things are improved. An anonymous complaint was received by the CSCI on 30th April 2007. The complainant alleged that there was no toilet paper for ten consecutive days, food seemed in short supply, the cleanliness of the home is poor, the home uses bank and agency staff and on some occasions they have done sleep-in duties on their first shift in the home, medication had not been given at the right time and had been given to the wrong person and the conduct of the Manager. This complaint was investigated during this visit and it was found that no Regulations had been breached. The home does use bank and agency staff and this is discussed further under the ‘Staffing’ section of this report. The Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 19 Manager and the Operations Manager said there have been previous similar complaints that have been dealt with by the organisation and where necessary this had been under the staff grievance procedure. The Operations Manager said that all staff were instructed to attend a meeting a fortnight before to ensure that all complaints made because of changes the Manager was making needed to stop and it was made clear what MIND expected of all staff to ensure that welfare of the people living in the home. A staff team-building day was arranged for the end of the month. The Manager said that he had made changes but he was certain that these are for the benefit of the people who live there but maybe not for staff. People said that they go to the post office to collect their benefits and pay their rent. Most people living in the home manage their own money. Money is kept in the safe for two people. Records showed that they receive their money when they ask for it. The amount on the record sampled cross-referenced with the amount in their cash tin indicating that it is being handled appropriately. Receipts were available of when the person had withdrawn their money from the post office. A financial risk assessment was in place for the person as they are at risk of giving money to strangers and being exploited so staff help them to keep their money safe. Staff training records showed that staff had received training in adult protection and the prevention of abuse. This ensures that staff have the knowledge of what to do if there is an allegation of abuse and how they can take steps to prevent abuse of the people living in the home. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 20 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, 26, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have continued but further improvement is needed to ensure that it is a homely and comfortable environment for the people who live there. EVIDENCE: The Manager said that the decorator should have started redecorating the bathrooms and toilets this week but they are now due to start the following week. New fittings and fixtures are also being provided in the bathrooms to make them more homely. People living in the home had been involved in choosing the colours for redecoration works. The lock on the WC next to the kitchen was not working. The Manager said he would ensure that this was repaired. The Manager said when he first started working at the home the kitchen was locked at 10pm but now it is open all night. He has had the tea bar removed Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 21 from the dining room as drinks can now be made in the kitchen. Staff had expressed concern about people using the deep fat fryer at night, which could be a fire risk so the Manager is looking for a plug lock that would be installed to reduce this risk. The Manager plans to use the tea bar area for computers that the people who live there can use. The Manager had submitted a quote for the office to be moved to what is currently the pantry and the current office to be used as a non-smoking room so that people can have a lounge they can sit in that would be smoke free, if they prefer. The laundry room had been redecorated in lighter colours so making it brighter. The paintwork on the walls of the hall was worn and in need of redecoration. The Manager said that if there were enough money in the budget this would be done in this financial year. One of the bedrooms was seen. This was very personalised, decorated to a good standard and kept clean. People living in the home said that they liked their bedrooms and had the furniture they needed. Bedroom doors were locked and people said that they had keys to their bedrooms and the front door so ensuring their privacy and maintaining their independence. At the rear of the home there is a large garden. The Manager said that they hope to create a herb garden as one person is interested in gardening and this could be a meaningful activity for them. Recently new crockery had been purchased and the cups, knives and dishwasher had been replaced so ensuring that good standards of hygiene are maintained. The home was clean and there were no offensive odours. People living in the home said that staff support them if needed to clean their bedrooms and they are expected to take part in this so maintaining their independence skills. The Manager said he is reviewing the cleaning schedules with the domestic staff to ensure that the home is kept clean. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development were variable and do not ensure that an effective staff team always supports the people living in the home. The recruitment practices ensure that the people living in the home are protected. EVIDENCE: Staff training records showed that all but one member of staff has NVQ level 2 or above in Care. This exceeds the standard that at least 50 of staff must have this qualification. The Manager had introduced a new six - week rota system. He said that this system is fairer to all staff as the previous system meant that part-time staff did not have as many weekends off as the full-time staff. It also ensures that hours can be used more effectively so benefiting the people who live there. There is a 10-6pm shift so that staff can support people to do things during the day. Two people need support from staff to go out. At the beginning of the visit there was one member of staff on duty as the other member of staff had rung Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 23 in sick that morning. The member of staff had telephoned the agency to cover but they had not arrived and did not arrive until 10.40am. The Manager said that there is are vacancies for one full-time and one parttime care officer and one full-time and one part-time care assistant. However they had recently recruited one full- time care officer and one part -time care assistant. The Operations Manager said that there is a freeze on jobs in the organisation as they are looking to re-deploy some staff from another service. One member of staff is on maternity leave. To cover the vacancies some staff work overtime and there is a bank list of about five people who work regularly at the home so they get to know the people who live there. Agency staff are also used but often they have not worked at the home before so they do not know the people living there. Staff meeting minutes showed that there had only been three meetings in the last year. There should be at least six each year to meet this standard and ensure staff know what is going on in the home and the organisation and are informed of any changes to the needs of the people living there. The Manager said that there was going to be a staff meeting that day but it was cancelled as staff were off sick. The recruitment records for the staff employed since the last inspection were seen and the required records were in place. These included a Criminal Records Bureau (CRB) check to ensure that suitable people are employed to work with the people living there. The Operations Manager said that those staff that applied for their last CRB three years ago are now in the process of applying again as is required to ensure that they have not had any criminal convictions since being employed. The Manager said that a training matrix is currently being developed by the organisation to identify the training and development needs of each member of staff to ensure they have the skills and knowledge to meet the needs of the people living in the home. Staff training records showed that one member of staff is doing the accredited ‘Safe Handling of Medicines’ course. Staff have received training in food hygiene, mental health, medicines, the prevention of abuse and risk assessment. As at the last inspection some staff last had fire safety training in February 2006 although since then they have watched a fire safety video as a refresher. The Operations Manager said that a Manager from the organisation is doing fire safety training and would then deliver this to staff across the organisation. The Manager said that staff have not had formal, supervision sessions as often as they should have but they are now trying to ensure that all staff receive these regularly. This will ensure that the performance of staff is monitored and Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 24 their training and development needs are identified so they can ensure a good service is delivered to the people living in the home. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that the people living in the home benefit from a well run home. The registration of the manager with the CSCI will ensure that this continues. Arrangements are in place so that the people living in the home can be confident that their views underpin all self-monitoring, review and development by the home. Arrangements are not always sufficient to ensure that the health, safety and welfare of the people living in the home is promoted and protected. EVIDENCE: The Manager has several years experience in a senior role of working with people who experience mental ill health. The Manager said that he gets a lot of guidance and help from the Operations Manager and also has regular formal Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 26 supervision. The Manager said that he submitted an application for registration with the CSCI in February 2007. However, this had not been received by the CSCI so another application was forwarded to the Manager. The Operations Manager said that the Manager has changed things since they have been at the home and this had caused some staff to raise grievances about him. However, he believes that the changes made are for the benefit of the people living there and improvement of the service. The home is owned by Focus Futures and Birmingham MIND provides the care and support to the people living there. A representative from Focus Futures visits the home on a quarterly basis to audit the service that is being provided. The National Mind organisation also undertakes a Quality Audit. Their standards need to be met so that Birmingham MIND can maintain their status as an organisation. A representative of the management committee of Birmingham MIND also visit the home and complete an audit. The Operations Manager said that they are in the process of recruiting people who use the service to sit on the bi-monthly residential committee. However, this is difficult and there is nobody currently living in the home that is interested in doing this. Fire records showed that regular fire drills are held so that people know what to do if there is a fire. The record of the last fire drill showed that one person refused to respond to the fire alarm. Their fire risk assessment needs to be updated to ensure that all risks of them not responding are minimised to ensure their safety if there was a fire. Staff test the fire alarm and emergency lighting regularly to make sure they are working. An engineer regularly services the fire equipment. When the fire officer visited they recommended that the door guards on the fire doors be replaced or removed to comply with current fire safety regulations. They also said that the lock on one person’s door needed to be changed so that in an emergency it could be opened from the outside and intumescent strips needed fitting on some of the doors to ensure that if there is a fire that smoke does not escape. The Manager said he is working through these to ensure they are met. Hazardous substances were kept in a locked cupboard so that people were not at risk of misusing them. A risk assessment was in place for leaving the kitchen unlocked at night as required at the last inspection. Risk assessments were also in place for using kitchen equipment and the premises. These had been reviewed and updated where necessary to ensure that all risks are minimised as much as possible. A Corgi registered engineer tested the gas equipment in April 2007 and stated that it was safe to use. An electrician tested the portable electrical appliances in January 2007 and stated that they were safe to use. The last five-yearly test of the electrical wiring was dated December 2000. The Manager was not sure if this had been completed as required in 2005 but was going to check with Focus Futures. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records stated that the sink in the kitchen on the ground floor was 55 Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 27 degrees centigrade and in the kitchenette was 45 degrees centigrade. The remaining temperatures were recorded as between 41 to 44 degrees centigrade. The recommended safe temperature to prevent scalds is 43 degrees centigrade. There was not a record of any action taken to reduce these temperatures. The kitchen sink on the ground floor may need to be warmer to ensure hygiene standards are maintained however, this must be risk assessed so that people are not at risk of being scalded. Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 28 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 2 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 2 X 2 X 3 X X 2 X Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 29 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4)(c) Requirement There must be a risk assessment in place for people who smoke in their bedrooms to ensure they and others living in the home are safe. Outstanding from last inspection. Timescale for action 30/06/07 2. YA20 13 (2) 3. YA24 23(2)(b) The lock on the medication 30/06/07 fridge must be repaired or replaced. This will ensure that the medication cannot be taken and used inappropriately which could cause harm to the people living in the home. The premises must be 30/11/07 maintained to ensure a wellmaintained and homely environment for the people living there. Partially met since last inspection. All locks on bathroom and toilet doors must be working to ensure the privacy of people living in the home. When the training matrix is developed staff must receive the training identified so they have the skills and knowledge to meet DS0000016865.V335224.R01.S.doc 4. YA24 12 (4) (a) 23 (2) (b) 18 (1) (a, c) 31/05/07 5. YA35 31/12/07 Hagley Road Version 5.2 Page 30 6. YA37 9(2) the needs of the people living in the home. An application for registration of the manager must be forwarded to the CSCI. Hot water outlets in the home must be assessed for the risk they present to the people living in the home and action taken to minimise any identified risk. Action must be taken to ensure that an electrician tests the electrical wiring of the home every five years so that it is safe. 31/07/07 7. YA42 13 (4) (ac) 30/06/07 8. YA42 13 (4) (ac) 30/06/07 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. Refer to Standard YA1 Good Practice Recommendations The service users guide should be updated with the current staffing and management arrangements. This is so that prospective service users know what is available to help them make an informed choice about whether or not to live there. Risk assessments should be regularly reviewed to ensure that appropriate support is given to individuals to minimise the risks to their health and welfare. There should be a running total of each medication on the Medication Administration Records to ensure that it is being given as prescribed. There should be at least six staff meetings a year so that staff have an opportunity to be kept informed of the needs of the people living in the home and how they can be met. All staff should have at least six formal, recorded supervision sessions each year so their performance is monitored and their training and development needs identified. 2. 3. 4. 5. YA9 YA20 YA33 YA36 Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 31 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 Hagley Road DS0000016865.V335224.R01.S.doc Version 5.2 Page 32 - 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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