Inspection on 16/09/05 for Hagley Road

This inspection was carried out on 16th September 2005.

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 no outstanding requirements from the previous inspection report, but 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 16/05/07

Hagley Road 17/10/06

Hagley Road 26/01/06

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 Kulwant Ghuman Unannounced Inspection 16th September 2005 10:30 Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 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.V250781.R01.S.doc Version 5.0 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.V250781.R01.S.doc Version 5.0 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 Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 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. 7th January 2005 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. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector and an observer carried out this inspection over part of a day in September 2005. It was the first of the statutory visits for 2005/2006. The inspection was carried out on an unannounced basis. There were nine residents living in the home at the time of the inspection. Three residents were spoken to and they all appeared to be happy with the care provided at the home. What the service does well: What has improved since the last inspection? What they could do better: Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 6 The home needs to continue the refurbishment programme so that the corridors are made brighter and more homely. Some issues regarding the removal of liquid soap by residents needs to be addressed so that there is liquid soap in all toilet areas so that personal hygiene practices are encouraged. The staff needed to update fire training and the home needed to ensure that all fire extinguishers were serviced. 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. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 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 Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Residents were enabled to visit the home before admission, which together with assessment ensures that the home could meet their needs. Residents were given licence agreements so that they knew of any terms and conditions of residence at the home. EVIDENCE: One of the residents said that he had visited the home before he came on a week’s trial and then decided to move into the home. He said that he had been given a licence agreement and keys to the front door of the house and his bedroom. The two new residents in the home had come from another of the organisation’s homes and both had settled well. One resident had moved on to supported living after receiving help to develop independent living skills. There were good interactions observed between the residents and the staff. There were documented strategies for managing any relapses in the residents’ mental health needs. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 9 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): 6,7,8,9,10 Residents were involved in writing up their Essential Lifestyle Plans and risk assessments. They were consulted about, and assisted, to make decisions about their daily lives. Support is provided to enable residents to achieve personal goals, and information about residents is well managed and securely held in the home. EVIDENCE: One resident file was sampled and showed evidence of assessments being carried out and reviewed on a regular basis. There was an Essential Lifestyle Plan in place and there was evidence that the resident had contributed to the writing of the plan. There were risk assessments in place that were regularly reviewed. There was evidence that another resident was being assisted to learn cooking skills and was able to use the microwave independently. Residents were assisted and encouraged to keep their own rooms tidy and laundry tasks undertaken. The majority of residents prepared their own breakfast but support was available if needed. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 10 There were regular residents meetings that were used to discuss holidays and menus. Residents were able to take risks and the risks were discussed with the residents. This included smoking in the home, taking medication as required and travelling on public transport. Records were stored appropriately in the home and there were good, professional interactions observed between the staff and residents. One of the resident’s permission was asked for before the inspector was able to inspect her financial records. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 11 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): 11,12,13,14,15,16,17 Residents were provided with opportunities to develop their skills, continue to be part of the local community, develop friendships and maintain contact with people important to them. They were given choices at meal times. EVIDENCE: The flat on the second floor was available for residents to develop their independent living skills before moving onto more independent supported housing schemes. At the time of this inspection there was no one in the home who was at this level of independence. Some of the residents went to the local shops and collected for items for the home. One of the residents went travelling on public transport and met with friends and relatives whilst another attended college. Relationships and friendships were respected in the home and shared accommodation was available. Several of the residents had been on a holiday during the summer and some were going on a trip to Blackpool. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 12 Residents were able to spend time in their bedrooms as evidenced during the inspection, they also had keys to the front door and were able to come and go as appropriate. There was a seven-week rolling menu in the home providing choices at all mealtimes. Menus were consulted on during the residents meetings. Residents usually prepared their own breakfast unless they requested a cooked breakfast. The residents said they were happy with the meals provided. Some of the residents helped to prepare the meals whilst others preferred to have their meals prepared for them. Residents could purchase takeaway meals if they preferred and money was provided for this. There was a vegetarian diet that was catered for in the home. The home was not currently recording what the residents were eating but were planning to start recording this in the future. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 13 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 Residents were supported with personal care if needed and their physical and mental heath needs were met. Medication was well managed in the home. EVIDENCE: The service users were all independent and required very little assistance in personal care. Some of the residents needed prompting to undertake some of these tasks. One of the residents told the inspector that they received regular visits to the doctor, or visits from the doctor if needed, and attended the clinic to see their consultant when needed. At the time of the inspection none of the residents held their own medicines, however, they did come to the office to get their medicines. The medication was very well managed. All medicines were appropriately booked in and running totals kept where needed. There were no controlled medicines in the home but there were facilities for storage and recording if needed. The temperature of the medicines fridge was monitored. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 14 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): 23 The residents in the home were protected from harm and they felt they could approach staff if they were unhappy with anything. EVIDENCE: The adult protection policy and complaints policy was not sampled during this inspection. One of the residents was clear that he would turn to the workers if there were anything that concerned him. There had been no complaints lodged with the CSCI regarding the home. There had been an issue of adult protection that had been raised and this issue was being dealt with at the time of the inspection. Staff had undertaken training in preventing abuse to ensure the protection of residents. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 The redecoration and replacement of furniture was ongoing in the home and this would continue to improve the physical environment. There were no offensive odours in the home. EVIDENCE: The home was suitable for the needs of the residents and well placed in the local community and accessible to community facilities. There had been some decoration work in the home including decoration of the lounge. The bathrooms, toilets and hallway were due to be decorated and this should help to brighten and freshen the home. New furniture for the lounge was on order. The lounge and dining room were homely and comfortable. The lounge was used as a smoking area for both staff and residents and extractor fans were in place. There was a suitable and accessible garden area. Only the communal areas of the home, a couple of bedrooms and the flat on the second floor were inspected during this inspection. Three residents had had new carpets laid in their bedrooms and three had had some new bedroom furniture. The bedrooms seen appeared to meet the needs of the residents and were personalised to the individuals liking. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 16 One of the residents reported that the kitchen was locked from 10pm in the evening until breakfast time. This was because the gas had been left on a previous occasion. Tea and snack making facilities had been made available in the dining room, however, the need to lock the kitchen must be kept under review to ensure that there is a need for it to be locked because of a specific risk and not because it had become custom and practice. There were sufficient bathing facilities in the home and provided the residents with a choice of bath or shower. The fitting of regulator valves controlled the hot water temperatures in the baths and showers to reduce the risk of scalding. All the residents were independent and able bodied so that the home did not require many adaptations. There were some grab rails in place in the bathroom on the ground floor and a walk in shower on the first floor. There was a bar of soap left in one of the shower rooms after a resident had showered. Staff must be vigilant in encouraging residents to return soap to their bedrooms after use. In the toilet next to the shower room and in one toilet on the ground floor there was no liquid soap. The inspector was told that residents walk away with the soap. The home needed to look at other ways of ensuring that soap is available in the toilet areas so that good hygiene practices can be encouraged. There were no offensive odours in the home. The laundry was accessible to residents and they were encouraged to take responsibility for their own laundry. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 17 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): 32,33,35 Adequate staffing levels were being maintained by a well-trained staff group that could meet the needs of the residents. EVIDENCE: There were a minimum of two support workers and a senior on duty at all times during the waking hours. There was one sleeping in staff at night. There was a domestic assistant who worked for four hours a day during the week. Staff and residents kept the home tidy during the weekends. One of the staff in the home had been employed in the home for three months but it was not evident that the induction had been completed. This needed to be completed within 6 weeks of employment. The member of staff was unsure of the actions to be taken in the event of a fire. As the manager was not on duty the recruitment procedures were not examined during this inspection. There was a good training programme in place for staff both internally and externally and included valuing diversity, protection from abuse, fire training and working with voices. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,41,42,43 The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was very well managed. EVIDENCE: The manager had recently successfully completed the registration process with CSCI and had become registered as the care manager. She had also completed the Registered Managers Award. It was obvious that there was an open and inclusive atmosphere in the home as evidenced by the fact that staff assisting in the inspection process were able to locate all the records required by the inspector except personnel records, as would be expected in line with confidentiality and data protection. There were regular staff and residents meetings in the home. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 19 Records sampled during the inspection included care planning documents, medication records, training records for staff, fire records and servicing of equipment. All the records were up to date and accessible. Health and safety was managed well with only three issues being raised: one of the fire extinguishers had not been serviced, fire training needed to be updated and although fire drills were being carried out it could not be determined that all staff were taking part in a drill every six months. There are regular visits to the home by the senior managers and there are regular reports provided to the CSCI. Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hagley Road Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 2 3 DS0000016865.V250781.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 Standard YA17 YA30 YA30 YA32 YA34 Regulation 17(2) Sch4(13) 13(3) 13(3) 18(1)(c) 19 Sch 2 Requirement A record must be kept of the food eaten by each resident. Staff must ensure that personal toiletries are returned to resident’s bedrooms. There must be liquid soap available in all communal toilets. Staff must undertake induction training within 6 weeks of commencing employment. Staffing records must be kept at the home and must include the following information: Next of kin & emergency contact number Training record Record and minutes of formal supervision Practice guidelines for staff full name address date of birth qualifications date commenced / ceased employment experience position held, work performed and number of hours Correspondence, reports of DS0000016865.V250781.R01.S.doc Timescale for action 01/11/05 28/10/05 28/10/05 01/11/05 01/12/05 Hagley Road Version 5.0 Page 22 5 6 7 YA42 YA42 YA42 disciplinary action and other employment records (Previous timescale of 1.5.05 not assessed for compliance.) 23(4)(c)(iv) The fire extinguisher in the office must be serviced. 23(4)(d) Fire training for staff must be updated. 23(4)(e) It must be ensured that all staff take part in a fire drill every six months. 01/11/05 01/11/05 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 23 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 Hagley Road DS0000016865.V250781.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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