Inspection on 16/09/09 for Hagley Road

This inspection was carried out on 16th September 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 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 15/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Hagley Road 429 Hagley Road Edgbaston Birmingham West Midlands B17 8BL Lead Inspector Sarah Bennett Key Unannounced Inspection 16th September 2009 09:35 Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 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 Nigel Timothy Higgins Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD) 10 The maximum number of service users who can be accommodated is: 10 23rd September 2008 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 is 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 people who live there being allowed time to develop and enhance the skills they have. The home allows the people living there to fulfil their potential and future goals in terms of their accommodation. The home is not suitable for people who use wheelchairs and this is stated in the service user’s guide. The service user’s guide stated the fees charged to live at the home were the block contract price for Birmingham City Council at £507.90 per week. Fees are negotiated individually if a person is placed from out of the city. There are no additional charges for any extra services provided. This information applied at Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 5 the time of inspection and the reader may want to obtain more up to date information from the care service. A copy of the last inspection report is available in the home for visitors to read if they wish to. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out over one day; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2009 to 2010. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and an Annual Quality Assurance Assessment (AQAA) completed by the manager. This provides information about the home and how they think it meets the needs of the people living there. We case tracked the care received by two people living there. This involved establishing individual’s experience of living in the care home by meeting and talking with them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. We looked at parts of the home and a sample of care, staff and health and safety records. The people living there, the manager and staff on duty were spoken with. What the service does well: Each person has a care plan. These are regularly reviewed and tell staff how to support individuals to achieve their goals. Staff know what each person needs and are aware if people’s needs change. People are supported to keep in touch with their family and friends so they can maintain relationships that are important to them. The people living there have opportunities to make choices and decisions about their lives. This helps to ensure their well being and improve their self esteem. Staff know the people living there well so they know how to support them. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 7 Staff have the training and support they need so they know how to meet the needs of the people living there. A relative said, ‘I am really pleased with how things are going, staff are caring and have the service users interests at the heart of what they do.’ People living there said they liked the staff and they supported them in the way they want. What has improved since the last inspection? Several rooms have been redecorated and new furniture has been bought. This has made the home more comfortable for the people living there. More activities are planned and people are being encouraged to take up new interests and hobbies. People are involved in a project about the history of the house which has included visits to places of interest, photography, gardening and art. People can go on holiday with staff if they want to. One person said they enjoyed their holiday and were looking forward to going again. A new manager has been appointed who has been registered with us. This shows their commitment to the home. Funding has been agreed to replace the kitchen cupboards and worktops so that the kitchen is clean and hygienic for people to store and prepare their food in. Staff regularly test the fire equipment to ensure that it is working and would protect the people living there if there was a fire. The service user’s guide includes the information needed so that prospective service users can make an informed choice about whether or not to live there. More support is given to individuals so that all their identified needs are met ensuring their well- being. The people living there have more opportunities to meet together to make choices and decisions about their lives in the home. This helps to ensure their well being and improve their self esteem. The people living there are encouraged and motivated to do their personal care helping to promote their dignity and self esteem. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 8 All the people living there know how to make a complaint so they would know what to do if they were unhappy with the service provided. This helps to ensure that people feel their views are listened to and acted on. All staff are aware of the Mental Capacity Act 2005 and how this legislation may affect the people who live there. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 9 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.V377778.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the information they need so they know their needs can be met there. EVIDENCE: Each service user has an assigned keyworker upon arrival but if a meaningful relationship cannot be formed then the service user has the opportunity to change to another member of staff. Since we last visited the statement of purpose and service user guide had been updated. It now included the range of fees charged to live there and the current manager details. It also included the outcome of our last inspection and what action has been taken to make improvements. The manager said that the service user’s guide is not provided in any other formats and most people are able to read. They said they could provide it in larger print if needed or as with the person who recently moved in delegate a member of staff to read it to them. Providing this document in other formats should be considered so that people would have the information they need to make a choice as to whether or not they want to live there. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 11 There were nine people living there. Since we last visited one person had moved on to independent living and another person had moved into the home. Their records showed that an assessment of their needs was completed before they moved in. The person, their relatives and other professionals were involved in the assessment. The AQAA stated that prospective service users are fully involved in the pre -admission process and with several visits they are able to get to know staff and the other people living there to assess what the home can offer. Our findings confirmed this and showed that the assessment process was detailed to ensure the person needs could be met. After the person moved in further meetings were held to ensure that their needs were being met there. An induction process was completed when the person moved in so that they knew where everything was and had a key worker they could ask if they were unsure of anything while settling in. The person said they had settled in well at the home. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff know how to support each person to meet their needs and achieve their goals and make choices and decisions about their lives. EVIDENCE: The records of two of the people living there were looked at. These included an individual care plan that was more detailed than at our last visit. This means that staff know how to support each person to meet their needs and achieve their goals. The person was involved in writing their plan with their key worker. It included what the person likes and dislikes so that their views are considered and support can be given as the person wants it. Each person has a key worker and they are consulted as to who this should be. Key workers complete monthly summaries about the person. This includes Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 13 reviewing how they have been supported to meet their goals and if any updates are needed to their care plan. The AQAA stated that there is a member of staff in the organisation whose role it is to promote service user involvement. A person living at another home within the organisation now chairs the meetings with the people living there. Staff are not present for the first half of the meeting but invited in for the second half to listen to points raised and then future action is decided.This is to help people raise any issues they have. Minutes of these meetings showed that this had recently started. Information about the meetings and when the next one was, was available in the home so that all the people living there would be aware of this. Minutes showed that four to six people often attended and talked about activities they would like to do, the decoration of the home and what they wanted and their responsibilities within the home. Information was available in the home as to how people could be involved in the running of the organisation, although none of the people living there were involved in this. One person had been involved in developing the equality and diversity plan for the home and had been paid for their time in doing this. Care plan review meetings include the person living there and any relatives or friends that they want to invite. Throughout the day people were observed to be involved in making choices and decisions about what they did, where they went, what they ate and drank and who they spent time with. Staff were available to support people where needed in making choices. Records showed that people had been involved in choosing colours for the redecoration of their bedrooms and communal areas. Records sampled included individual risk assessments. A general risk assessment was completed for each person that was not very detailed. However, where this identified risks to the person more detailed assessments were written. These included the risk of the person’s mental health relapsing so that staff knew what signs to look for and how to help the person to reduce the risks. The person had signed to say they had contributed to their risk assessments and that they agreed to actions needed from staff where appropriate. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 14 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): This is what people staying in this care home experience: 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to experience a meaningful lifestyle of their choice so improving their well being. EVIDENCE: One person had started a literacy course at a local college that morning. They were supported by staff to attend this and were discussing with staff what equipment they needed to buy to help them with their course. A computer has been provided that people can use in the home so they can develop their IT skills. Records showed and people said that they go shopping, to the pub, to restaurants and swimming.Several people regularly go to local shops either on their own or supported by staff if needed. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 15 The AQAA stated that they have improved activities by having an ongoing project on the history of the house and garden with the air raid shelter being re-opened and work being done to restore the original garden paths and rockeries. Some people living there had been involved in this by taking photographs of the house that were displayed in the dining room. One person proudly showed us these during the day. Some people had done some art work related to this project although the art worker was not working at the home any longer. The manager was trying to recruit another art volunteer worker as the art sessions had been popular and useful for some people living there. Outings were being arranged to places of interest that linked in with the history of the house. Staff said that it was difficult to motivate some people living there to do things even for holidays and day trips. Records showed that only a few people wanted to go on day trips despite their involvement in choosing where they wanted to go. One person had been on holiday with staff and was going again soon with staff and another person living there. They said that they really enjoyed the holidays and day trips and showed us photographs of a recent day trip to Burnham–on–sea. Records showed and it was observed that staff tried to involve all the people living there in activities but people were often reluctant to do these. However, it was observed that some people had made small steps in getting involved in some things such as helping with or showing an interest in the garden project. Staff were determined that these small steps would be built on as individual’s developed their interests. Most people have lived at the home for many years and have not always been motivated by staff to develop or maintain their hobbies and interests. Therefore, staff are to be commended for their perseverance and creativity in trying to motivate people to improve their experiences and lifestyles. Records sampled showed and people said that they are supported to maintain contact with their family and friends. One person went out with a relative for lunch. Their relative was happy with the support given to the person and pleased that they had the opportunity to go on holiday with staff this year. Another person said they often visited their relative. A phone had recently been provided in the small lounge for people to use that was free of charge. People had also been encouraged to make friends with people who live in another home run by the organisation. This has helped to develop people’s social networks. Records sampled showed and it was observed that people are encouraged to develop their independence skills. People do their own laundry with support from staff as needed. People make their own drinks and some people help staff with cooking. People are supported to clean and tidy their own bedrooms. A cleaner is employed to clean the communal areas of the home. They were observed to support people to develop their skills and obviously knew the Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 16 people living there well, what they were able to do and where they may need some assistance. Records sampled included information about the person’s dietary needs and staff said these were catered for. Staff said that on Wednesdays and Saturdays they do a cooked English breakfast/brunch for people. People were observed to enjoy this and had it when they wanted either in their bedroom or the dining room. Staff said that people have a ‘lighter’ tea although later people had pie and chips for tea. Records showed that some people needed help to lose weight to be healthy. Since we last visited records are kept of all food provided to each person living there. This shows that people are being supported to have a healthy diet. There was a bowl of fresh fruit on the dining room table and people were observed taking what they wanted during the day. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living there receive support with their personal care in they way they want but are not always well supported to meet their health needs. EVIDENCE: The people living there were dressed in individual styles that reflected their age, gender and the activities they were doing. People had been supported with their personal care. Where further support was needed staff discreetly offered this trying to motivate people to ensure their self esteem and well being. The manager said and the AQAA stated that they now have a link worker from the Community Mental Health Team who will visit the home regularly to spend time with the people living there. This will help to ensure that people get the support they need with their mental health and access services they need to improve their well being. The manager said and records showed that all people’s ‘Care Programme Approach’ assessments are to be updated to ensure Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 18 that people are getting the support they need from the relevant support services. Records showed that one person had been referred for art therapy and also for 1:1 sessions to support them with their ‘voices’. The person said they were pleased with this and felt they were now getting more support with their mental health needs. The AQAA stated and the manager said that two people are being supported by a continence advisor to help them and from this where needed referrals had been made to other health professionals. One outcome of this was that all people were being encouraged to drink less caffeine and try some caffeine free drinks. This may be of benefit to people’s physical and mental health. One person’s records sampled showed that they had asthma but there was not a care plan as to how staff were to support them with this. Their medication records showed that the person takes an inhaler to relieve their asthma which they are able to administer themselves. They were also prescribed an inhaler to prevent their asthma. Their record showed that they often refused this. The manager was not aware of the differences between the inhalers and therefore of the importance to take advice from the GP if the person refuses this. The GP did not regularly review the person’s asthma. The manager said that the person does attend outpatient appointments regarding their breathing function but records showed that no changes had been made to their inhaler medications as a result of this or that their use had been reviewed. Records sampled showed better recording by staff of health appointments that people had attended. This helps staff to follow health professional’s advice to support people to meet their health needs. Records of how staff perceived people’s moods had improved. This makes it easier for staff to monitor if a person’s mental health is deteriorating so that action could be taken where necessary. People said that staff spend time talking to them when they hear voices and it is good to have someone to talk to about it. Records showed that staff spent time talking to people when they had a restless night so they could find out if anything was troubling them. Records showed that people’s weight was monitored regularly where they agreed to being weighed. This is important as a significant loss or gain of weight could be an indicator of an underlying health need. The AQAA stated that all staff had now attended training in medication. Medication records sampled showed that people had signed to say that they agreed to have their medication. The pharmacist supplies the medication weekly in individual dosage packs to make it easier for staff to know how much and when to give people their medication so minimising the risk of errors. Medication sampled showed that one person had refused their medication that morning. The reason for this was stated on the back of their Medication Administration Record (MAR) as they had gone out early that day. They had Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 19 not been given an opportunity to take it when they returned home so they missed that dose. This could affect their health if each time they went out early they missed a dose of their medication. The manager said they would address this with staff. The MAR were hand written which could result in errors being made, for example one person’s as required medication was misspelt on their MAR. If the person had to be admitted to hospital their MAR would not assist staff there in being able to know exactly what medication the person is prescribed or has been given which could affect their health. There was a photograph of the person attached to their MAR so that unfamiliar staff would know who to give the medication to. Some people were prescribed as required (PRN) medication. There was not a protocol in place that stated when, why and how much of the medication should be given to the person. The manager said that one person asks for their PRN medication as they know when they need it. This was not stated so that it is clear that all staff know this and how much it is safe for the person to have which could impact on their health. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements ensure that the views of the people living there are listened to and they are protected from harm. EVIDENCE: The complaints procedure was available in the service users guide which all the people living there have a copy of. It stated how people could complain, and what action will be taken and when. Our contact details were out of date so that people may not know how to contact us if they wanted to. The AQAA stated that the people living there now have access to an advocacy service that they can contact if they need help to raise concerns about the home. Their details were displayed in the home. The AQAA stated that since we last visited they have received five complaints, four of which were upheld. They were all responded to within 28 days as stated in the complaints procedure. The complaints log confirmed this and showed that appropriate action was taken to make improvements to the service as a result of people complaining. We have not received any complaints about the service provided at the home since our last visit. The AQAA stated that the organisations safeguarding training has been updated and all staff now attended this. Training records showed that Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 21 refresher training is being arranged for staff. Staff meeting minutes showed that the updated Birmingham City Council safeguarding guidelines were discussed at a recent meeting and these were available in the home. This ensures that staff are aware of what to do to protect the people living there from abuse. The AQAA stated and training records confirmed that most staff had now attended Mental Capacity Act training or had dates arranged to do this. The manager said that they do not keep money for any of the people living there in the safe. The people living there or their relatives manage their money and spend as they wish. Support is given from staff where needed with budgeting. Records showed that before staff start working at the home a Criminal Records Bureau (CRB) check is completed to ensure that ‘suitable’ staff are employed. After three years another CRB check is completed to ensure that staff have not received any criminal convictions during that time. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made to make the home more comfortable for people to live in. EVIDENCE: The AQAA stated and it was observed that the dining room chairs had been replaced and the room redecorated. This had made it more homely and comfortable for the people living there. Staff said a lot of redecoration had been done since the manager started, which is improving the home for the people living there. Several areas of the home were being redecorated to make it more comfortable for people to live in. This had made the home look brighter and more homely. People said they had been involved in choosing the colour schemes for this. The redecoration programme is being done by the probation Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 23 services Community Payback Scheme. The manager said in the AQAA that the process is slower than if we had used a commercial decorator but we have saved several thousand pounds. A risk assessment was in place for the decorating but this referred to the materials being used and people being at risk of getting paint on them. It did not refer to the risks that may be there from using this team. The manager said that the people in the team are low risk offenders but this was not stated in a risk assessment so it is not clear that the people living there are safeguarded. The smoking lounge had been redecorated and one of the sofas’s removed, making the room look bigger and more comfortable. The manager said that measurements had been taken to replace the curtains in there. The non smoking lounge was homely and comfortable. The computer and printer have been replaced for the people living there to use. The manager said that work on the kitchen was due to commence at the end of the month and contractors had been appointed. The people living there have chosen the new flooring and units. A new cooker is also being provided. Plans are in place to ensure that people can have meals at the home and make drinks and snacks in the dining room while the kitchen is being refurbished. The bedrooms of two of the people living there were looked at. These were personalised to individual tastes and interests and contained people’s personal possessions. One bedroom had been redecorated and an extractor fan fitted as staff know that the people living there smoke in there. The curtains and lampshades have also been replaced making it more comfortable. Some furniture in bedrooms has been replaced. The home has been successful in obtaining a ‘community chest’ grant to replace some other bedroom furniture. The AQAA stated that the rear garden had significantly improved with restoration of the old paths, flower beds and rockeries. Much excess growth has been cleared, allowing natural light to flow into some bedrooms. The World War II air raid shelter has been cleared and reopened, adding useful storage space and adding a new facet to the history of the house and garden project. It was observed that a lot of work had been done in the garden. The manager has submitted a bid to ‘Eco Minds’ for further work in the garden and a volunteer is also involved. Some of the people living there had begun to take an interest in this. The manager said that the external areas need redecorating but Midland Heart had said they would not be doing this in this financial year. The manager said in the AQAA that they will continue to pursue this. The home was clean and free from offensive odours. The laundry had been redecorated making it look cleaner and more hygienic. The manager said that they hoped to replace the laundry room cupboards but had not yet been able to. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for staffing, their support and development generally ensure that the people living there are well supported by staff who know them well. EVIDENCE: The AQAA stated that four staff have completed National Vocational Qualification (NVQ) at level 3 or above. Records showed that four staff had recently registered to start NVQ level 2. This will ensure that all staff have the skills and qualifications so they can meet the needs of the people living there. The AQAA stated and the manager said that they are now fully staffed. This ensures that people are supported by staff who know them well. Good interactions were observed throughout the day between staff and the people living there. Staff were observed to know people well and know what support each person needed. Rotas sampled showed that there are at least two staff on each shift and sometimes there are three. The manager is additional to the rota so they have time to concentrate on management tasks. At night there is one member of staff sleeping in on the premises. The manager said and rotas Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 25 showed that agency staff are not used to cover shifts. Where needed the organisation have its own bank staff who cover shifts and these staff know the people who live there. Staff meeting minutes showed that these are usually held monthly. Staff are updated with new guidelines and changes in the organisation. They discuss what is going on in the home and how to support the living there. The manager said that the staff recruitment records are held at their Head office. The manager said that they know that all staff have a Criminal Records Bureau (CRB) check completed before they start working at the home. Following our visit the manager forwarded us evidence that all staff employed at the home have a current CRB check that shows that ‘suitable’ people are employed to work with the people living there. Records showed that when staff started working at the home they received an induction. Most staff had worked in the organisation before they started working at the home. However, they still had an induction so they knew how to support the individual’s living there. Training records showed that staff receive the training they need so they know how to support the people living there to meet their needs and achieve their goals. Where staff need refresher training records showed that these were being booked so that staff’s knowledge can be updated. Staff said they had done a lot of training, most recently on the Mental Capacity Act and had refresher training booked in the next few months. The AQAA stated that the organisation has been awarded an ‘Investors in People’ award. This means that they should be offering staff the training, development and support they need in their job role. Staff records sampled showed that staff had regular supervision sessions with their manager. This ensures that staff are supported and their training and development needs are identified so they know how to support the people living there. The AQAA stated that a new staff appraisal system was in place and all staff have had their first appraisal meetings. Staff records sampled confirmed this and staff had set objectives to meet in the next year. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management arrangements generally ensure that the home is well run and promotes the views of the people living there and their safety. EVIDENCE: Since our last visit a new manager had been appointed who has been registered with us. The manager has completed NVQ level 4 in Care and is waiting for this to be assessed. The statement of purpose stated that the manger has already completed NVQ level 4 in management. The manager has several years of management experience with in the organisation so they have the skills and experience needed to manage the home. Staff said that there Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 27 have been a lot of changes for the better since the manager started working there. The manager said that an equality and diversity plan has been developed for the home. One person living there was involved and was paid for this. From this an action plan was developed to make improvements to how the home meets the diverse needs of the people living there or people who may live there in the future. One action is to investigate putting a ramp so the front door of the home is more accessible. Another action was that a higher level of community engagement was needed. We found that improvements have begun to be made in this area. The home has a ‘Quality Group’ that is led by a member of staff who works there. However, this member of staff had been off sick since July this year so this group had not been active since then. The AQAA stated that the home had been given an ‘Excellent’ rating at the last Quality review by the national Mind organisation. The manager said that the quality group helps to keep up these standards. A representative from the committee of the organisation visits every three months. The report of their visit in July this year showed that they looked at the building, spoke to the people living there about meals and activities people do, whether people can make decisions about the running of the home and any complaints made. The report stated: ‘Obvious effort on the part of the manager and staff to stimulate and improve the lives of residents.’ We also found this during our visit. The manager said that the Operations manager visits the home every month but there were no reports of these available. Reports of these monthly visits should be available to ensure that action is taken where improvements are needed. Staff test the water temperatures weekly to make sure that people are not at risk of being scalded. Records showed that these were within the recommended temperatures to prevent people being scalded. Some water in the sinks in people’s bedrooms was cool. This had been reported to the maintenance team and the manager said this was an ongoing problem due to the age of the plumbing. Since we last visited the fire risk assessment had been reviewed to ensure that the risks of there being a fire are minimised as much as possible. Staff had signed to say they had read this so they knew what to do to help to keep people safe. Fire records showed that staff regularly tested the fire equipment to make sure it is working. An engineer regularly services the fire equipment to ensure it is well maintained and would work if needed. The records stated that the last fire drill was in January this year. These should be held at least Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 28 every six months so that the people living there and staff would know what to do if there was a fire. The AQAA stated that electrical and gas equipment is regularly serviced and tested to ensure it is safe to use. As stated earlier in this report there was not a thorough risk assessment on the decorating that was taking place. This should include the team that is being used to do this to ensure that the people living there are safeguarded from harm. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 29 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 3 3 X 4 3 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 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Version 5.3 Page 30 Hagley Road DS0000016865.V377778.R01.S.doc No 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 YA19 Regulation 12(1) (a) Requirement Care plans must include how staff are to support the person with all their health needs so ensuring their well being. Regular fire drills must be held to ensure that the people living there and staff would know what to do if there was a fire. Timescale for action 30/11/09 2. YA42 13 (4) 31/10/09 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 Consideration should be given to providing the service users guide in other formats so that people would have the information they need to make a choice as to whether or not they want to live there. Staff should support people to ensure that all their health needs are regularly reviewed by health professionals to ensure they are met. Consideration should be given to having the Medication Administration Records printed by the pharmacist to avoid any errors which could impact on people’s health. Protocols should be in place for all as required (PRN) DS0000016865.V377778.R01.S.doc Version 5.3 Page 31 2. 3. 4. YA19 YA20 YA20 Hagley Road 5. 6. 7. YA24 YA39 YA42 medication so that it is clear for staff to know when people should have this and how much to ensure their well being. The external areas of the home should be redecorated to ensure it is well maintained. Reports of the monthly visits by a representative of the organisation should be available to ensure that action is taken where improvements are needed. Risk assessments should include all areas of risk to ensure that the people living there are safeguarded from harm. Hagley Road DS0000016865.V377778.R01.S.doc Version 5.3 Page 32 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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