Inspection on 17/10/06 for Hagley Road

This inspection was carried out on 17th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 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 Kulwant Ghuman Key Unannounced Inspection 17th October 2006 09:00 Hagley Road DS0000016865.V307271.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.V307271.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.V307271.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 Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Hagley Road DS0000016865.V307271.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. 26th January 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. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key, unannounced inspection was carried out by one inspector over one day during October 2006. During the inspection the inspector was able to speak with two staff and the manager of the home, six of the nine residents, tour the communal areas of the home and see three bedrooms, sample one staff file and several care and health and safety records. Since the last inspection a new manager had been appointed to manage the home. Prior to the inspection the manager had completed and returned the preinspection questionnaire that provided some information about the home. The inspector also received eight completed comment cards from the residents, two from relatives and two from visiting professionals. The relatives and professionals were all happy about the care provided at the home. The relatives and some of the residents indicated that they were not sure of the home’s complaint procedure. Some of the residents comment cards also indicated that they were not happy with the food provided at the home, they did not always feel safe and sometimes their privacy was not respected. Since the last inspection in January 2006 one complaint had been lodged with the CSCI, regarding several areas of the management of the home. The complaint was referred back to the provider for it to be investigated. The complaint raised issues of an under spend on the food budget, menus being changed without consulting the residents, not having sufficient milk, crisps and cakes available and not ensuring that a diabetic diet was followed. These aspects were not upheld. There was an issue of some tools being left out and accessible to residents and not making sure that a work surface was safe in one of the resident’s bedroom. These issues were upheld. It was alleged that a new member of staff had not been given a sufficiently detailed induction to enable the individual to undertake their duties. This issue was also not upheld. What the service does well: The home continues to be provide a home for residents with enduring mental health issues, some of whom have lived at the home for many years. There are good relationships between the staff and residents and the staff know the needs of the residents well. The residents are enabled to lead individualised lives that met their needs and are encouraged to take responsibility for everyday tasks. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 6 There were good systems in place to ensure that the residents’ health care needs were being met and that they received their medication as prescribed. What has improved since the last inspection? What they could do better: This was a time of change for the home and time was needed for the staff and residents to adjust to the new management style in the home. The care plans needed to be improved so that there were clear goals for the residents to be working towards and an indication on how the goals were to be achieved and what was to happen if they were not being achieved. The monthly summaries needed to be carried out regularly for all residents. Risk assessments needed to be in place for managing the risks presented by residents smoking in their bedrooms. There needed to be cleaning schedules in place to ensure that the home was maintained at a satisfactory level, including high level dusting and cleaning of curtains and dining chairs. There were some areas of the home that needed to be addressed in terms of damp and redecorating. All cleaning items needed to be stored in a locked cupboard. The manager needed to ensure that the work surface identified in the complaint was secured and made safe. The manager needed to ensure that staff completed their induction within twelve weeks of starting their employment and that the induction records showed that they had been given the relevant information before being asked to undertake tasks they were responsible for, for example, fire procedures. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 7 Fire training needed to be arranged for the staff. 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.V307271.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.V307271.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had sufficient information available to them to enable them to know what the services offered at the home were and what their rights were. EVIDENCE: The statement of purpose and service user guide were available in the home. A minor amendment needed to be made to the complaints procedure within the service user guide that referred to the NCSC instead of the CSCI. There had been no new admissions to the home since the last inspection. The two resident files sampled during the inspection had a licence agreement in place. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ needs were well known by the staff but the records needed to be clear about what the goals for each individual were and how they were to be achieved. EVIDENCE: There were Lifestyle Plans in place that evidenced that the residents were involved in drawing them up. The information involved in them was limited and did not clarify what the goals were and how or when they would be achieved. In addition to the Lifestyle Plans there were risk assessments that identified potential risks and identified triggers for staff to be aware of. There were also regular reviews in line with the care management approach. Monthly summaries were undertaken for the residents. The two files sampled had monthly summaries available however, for one the last summary was undertaken in June 2006 and for the other August 2006. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 11 The residents were able to make decisions about their lives on a daily basis, eg prompted with personal care, what to eat, encouraged to go to the local shops and this was generally because the staff had developed an in depth knowledge of the residents. The Lifestyle Plans and monthly reviews did not evidence the amount of interaction needed with the residents and there were no identified plans in place to ensure that a consistent approach was followed by all staff when the residents did not follow their plans. For example, where residents were to be supported and encouraged with personal care or not to isolate themselves in their bedrooms there was no indication of what actions the staff needed to take if the resident refused to take a shower or get out of bed, or how long to wait until they were approached again. The residents were able to make decisions and staff attempted to guide them into making informed decisions wherever possible. There was evidence that residents were advised and supported when they were getting into difficulties, for example, financial. Residents were encouraged to develop independent lifestyles by encouraging them to take responsibility for going to the shops for their own takeaway meals. Where they were unable or did not want to go out they were encouraged to carry out other tasks for the person going out for them as a means of acknowledging their assistance. Residents were able to smoke in their bedrooms. During the tour of the building the inspector noted that one residents ashtray was overflowing. The manager was not aware of any individual risk assessments covering residents smoking in bedrooms. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with opportunities to develop their skills and continued to be part of the local community. Opportunities for residents not going out very often needed to be discussed with them to ensure their needs were being met. EVIDENCE: Residents were assisted to take up opportunities for personal development. Lifestyle plans highlighted areas where residents wanted to develop for example, learning to cook. Residents were supported to undertake these tasks. Daily routines were found to be individualised, one resident continued to go out very early in the morning and visit relatives and return later in the day. Another resident had recently started to visit the library and had developed from being taken to the library by staff to being able to go independently. Another resident continued to attend college. A couple of residents tended to stay in bed until later in the morning and then spend time in the lounge. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 13 Two residents continued to share a bedroom as was their wish. All residents were encouraged to take responsibility for the cleaning of their bedrooms and personal laundry. They were encouraged to go to the local shops to purchase items they required and also to run errands for the home. Two residents had been to Scotland for a week and an overnight stay in Blackpool had been organised for those wanting to take part. Some residents told the inspector they were not interested in having a holiday. Residents liked to go out to the local pub and somewhere to eat but otherwise tended not to go out very much in the evenings. The manager discussed this issue with the inspector as he was not sure about organising activities in the home as the organisation preferred to encourage residents to go out as much as possible. This was an issue that needed to be discussed with the residents and if it is was something that they would value then consideration should be given to organising activities that they identified. Prior to the inspection several comment cards had been completed by residents and returned to the inspector. Three of the eight responses stated that they did not like the food. During the inspection residents stated that they were happy with the food, however, one resident stated that they were no longer given a supper, which they always used to have. The manager was not aware that this was the case but confirmed that supper was not identified on the menus but that sandwiches etc would be available. The inspector also noted that in one of the residents daily records it had been recorded a couple of times during the end of August/beginning of September that the resident was unhappy with there being too many salads on the menu. The manager confirmed that the menus had been changed but that they were going to be changed again to be more seasonally appropriate. There was a list of preferences gathered from the residents. The menus showed that there was a variety of meals available but if the residents did not want what was available they were supported to get something else. The home had started to record what the residents were eating as suggested at the last inspection. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents physical, emotional and mental heath needs were being met. EVIDENCE: The majority of residents were able to undertake personal care tasks however, several needed prompting and encouraging to undertake these tasks. As stated earlier, the staff needed to be consistent in their approaches with individuals and there needed to be written guidance about this. The manager acknowledged that there were some gaps in the care plans and was hoping to develop the documentation in the future. The manager informed the inspector that on some occasions when there had been difficulties in getting a resident to undertake personal care tasks he had spoken to the individuals on a one to one basis and this had had the desired effect. This was not evident from the records seen. Residents were supported with their emotional needs. One resident had become distressed at not having been dropped off at the correct bus stop by a bus driver. The resident was escorted to the bus stop, ensuring the driver knew where they wanted to get off until the resident gained confidence again. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 15 Residents’ health care needs were being met. Residents were assisted to attend appointments at the hospitals or local health centres. Referrals were made where required to the mental health teams. Residents not able to self administer their medicines were required to come to the office at the appropriate times for their medicines. One resident was able to manage their own medicines. The home used a seven day monitored dosage system. Records were well maintained and amounts of medicines booked into the home appropriately. There was evidence of blood tests being carried out where required. There were no controlled medicines in the home but the facilities were available if required. There was a medication fridge available for which the temperatures were recorded on a regular basis. The inspector was informed that staff had undertaken training in handling medicines but it was not clear that this was accredited training in the safe handling of medicines. The manager needed to ensure that the training was equivalent to the accredited training. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints arising in the home are appropriately investigated but the relatives and residents in the home must be reminded of the process so that they are enabled to raise any issues of concern. EVIDENCE: There was a complaint leaflet in place that needed a minor amendment as it referred to the NCSC and not the CSCI. The home had monthly return system for complaints. There had been no complaints logged from March to July 2006. There were no returns found for August and September although it was confirmed that there had been no complaints lodged with the home directly. A complaint had been raised by one resident about another resident and the manager had dealt with it but it had not yet been written up. A complaint was lodged with the CSCI on 29/08/06 and was forwarded to the organisation for them to investigate. A response following the investigation was sent to the CSCI within four weeks. Some of the issues raised in the complaint related to food including a possible under spend on the food budget and residents having to purchase items such as crisps and cakes, the home running out of milk, the traditional take away meal being moved to Wednesday night instead of Saturday, sweet items such as biscuits being available to residents with diabetes. The response found that: Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 17 • • • • • • • • • • • Items such as milk, crisps and cakes had run out as the food cupboard was no longer locked up but that petty cash was provided for the residents to go and get more. The traditional Saturday night take away was being reinstated and the menus had been adjusted to incorporate healthy eating. Issues such as holidays not being arranged had been discussed with the residents. Tools in the office had been removed and appropriately stored. Risk assessments had been reviewed. The manager did not leave the premises without informing the staff. The new member of staff had been provided with induction. A resident was provided with a kettle and fridge and the work surface had been rectified. A resident had been assisted to pay of accommodation arrears but this was with the resident’s consent. Residents meetings were to be held regularly. Staff supervisions would be closely monitored. At the inspection the manager informed the inspector that the work surface had not been fixed but he had brought in the drill. The drill was in the corner of the room. The comment cards completed by the residents and relatives indicated that some people were not aware of the home’s complaints procedures. The inspector was informed that there had been no issues of adult protection that had arisen at the home. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were some areas of the home that needed cleaning and decorating but in general the environment met the needs of the residents. EVIDENCE: The home continued to meet the needs of the residents. The location of the home meant that local community facilities were available and there was an accessible bus service-taking residents into Birmingham city centre. Since the last inspection the physical standards in the home had declined. The decor in some areas of the home needed to be attended to, for example, in the corridor outside the office, the dining room to ensure a homely, clean and well maintained environment was maintained for the residents. The main lounge was comfortable with television, comfortable seating and coffee tables. Staff and residents smoked in the lounge. There was nowhere for non-smokers to sit comfortably in the home. This issue had been raised previously but there did not appear to have been any progress with this issue. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 19 The dining room was able to seat all the residents if they wanted to eat all together. The chairs and net curtains in the dining room were found to be in need of cleaning. By the end of the inspection the curtains were being washed. The tea making facilities that were previously located in the dining room had been removed. The area around this work surface was unsightly and dirty. The manager stated that some of it was due to a leak and he was working towards having it addressed. The kitchen was no longer locked after 10pm. There was a bathing facility on each of the floors that provided residents with a choice of bath and shower. The home needed to look at how the bathing facilities and toilets could be made more homely, particularly on the ground and second floor. Water temperatures were appropriately controlled. One of the showers was not working and had been reported. During the inspection another telephone call was made by the manager to express his annoyance at the time it was taking to get the work done. All the residents were mobile and did not need many adaptations. During the tour of the premises three of the residents’ bedrooms were seen. The occupants of the other bedrooms did not respond on knocking the doors so the inspector did not go into them. One of the bedrooms was a shared room. There was privacy curtain available in the room. When one of the residents had visitors the curtain could be drawn for some privacy if the other resident was in the room. There was nowhere else that the residents’ could meet with anyone in private. The independence flat on the second floor had been occupied by one of the residents who was developing some independence skills. All the residents said they were happy with their bedrooms and the bedrooms sampled all had sufficient furniture to meet the residents’ needs. Bedroom doors were locked and the residents said they had keys to their bedrooms and the front door. The laundry door was wedged open and Domestos was stored on top of the cupboards. All items covered by the COSHH regulations must be locked away when not in use. The garden area was not inspected at this inspection. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well-supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained and support was being provided to the residents by a well-trained staff group. EVIDENCE: One member of staff had been employed since the last inspection. The file of this member of staff was sampled and found that it was all in order. All the appropriate checks had been undertaken to safeguard the residents. An induction had been started however it had not been completed. The fire orientation had not been signed or dated. The manager needed to ensure that induction training was undertaken within twelve weeks of starting employment and that they had been given all the required information before they undertook shifts where they were in sole charge. The home were waiting for two new members of staff to start work in the next few weeks. One member of staff was on maternity leave, another was on secondment and there were one and half posts vacant. The staff were undertaking long shifts or bank staff were used to ensure that there were always two staff on duty during the day and one sleeping in member of staff at night. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 21 70 of the staff had undertaken NVQ level 2 training. There was one domestic assistant who worked at the home for four hours Monday to Friday. The domestic assistant was responsible for cleaning the communal areas of the home. The manager needed to ensure there was a cleaning schedule in place to ensure that dusting and higher level cleaning was undertaken on a regular basis. The staff had all received a substantial amount of training in the past. There had not been a lot of training since the last inspection. The manager had started to set up a training matrix for staff to identify what training had taken place and what training was required for their development. The fire training for staff was last undertaken in February 2006 and needed to be undertaken again. The staff were very knowledgeable about the residents’ needs and were able to appropriately support them. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39, 42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager needs to undertake more consultation with the residents and staff when changes are introduced into the home to ensure that they feel involved in the changes and that the changes are in their best interests. EVIDENCE: Since the last inspection the registered manager had moved to another post and a new manager had been appointed. The manager needed to submit an application for registration to the CSCI so that the residents were assured that a responsible individual was in place to look after the needs of the home on a day-to-day basis. There was necessarily a period of time during which the new manager needed to settle into the role and the staff and residents needed to get accustomed to a new management style. The manager had made some changes in the home. Some of these had been welcomed some had not. It was difficult at Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 23 this inspection to comment on the managers ethos and leadership as he had not been in post long enough. There were some positive actions being taken on behalf of the residents, for example, not locking the kitchen in the evening and plans for leaving the store cupboard open. Appropriate risk assessments needed to be put in place to minimise risks as far as possible whilst allowing some controlled risk taking by the residents. Comment cards from the residents indicated that not all residents were happy. Some of them felt that their privacy was not always respected and some did not always feel safe. It was important that the residents were reassured that their views would be taken into consideration and key workers needed to ensure that any reasons for residents feeling any dissatisfaction were taken seriously and reported. Regular resident meetings needed to be carried out so that the residents could be involved in the decisions being made about the way in which the home was run. Staff informed the inspector that meetings were carried out with the residents, however, only minutes for two meetings were available (June and September 2006) The maintenance of equipment in the home was undertaken as required and health and safety in the home was generally well managed. One aspect of the complaint received by the CSCI had been in respect of an unsecured worktop in one of the resident’s bedrooms. This had not been addressed at the time of the inspection. Fire training for staff was overdue and some COSHH items had not been locked away. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 2 2 Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA4 Regulation 12(1)(a) Requirement Timescale for action 01/12/06 2. YA6 15(1) All residents must be provided with the opportunity to get to know the residents and home before making a decision whether to move to the home. (Not assessed for compliance at this inspection. The requirement has been carried forward.) 01/01/07 Action plans and ELP’s must clearly identify how the goals are to be achieved. (Previous timescale of 01/04/06 not met.) Care plans must be reviewed on a monthly basis. Staff must be consistent in the action they take when residents do not undertake the tasks identified in their care plans. There must be a risk assessment in place for residents who smoke in their bedrooms. The need for activities in the home must be discussed with the residents. A menu must be drawn up after consultation with the residents and supper must be identified on the menu. DS0000016865.V307271.R01.S.doc 3. 4. 5. YA9 YA14 YA17 13(4)(c) 16(2)(n) 17(2) Sch4(13 01/12/06 01/01/07 01/01/07 Hagley Road Version 5.2 Page 26 6. YA20 18(1)(a) 7. 8. YA22 YA23 2(5) 13(6) The manager must ensure that staff have undertaken accredited training in the safe handling of medicines. A copy of the complaints procedure must be given to all residents and relatives. The adult protection procedures must be reviewed to make clear the actions to be taken in the event of an allegation or incident of abuse. (Not assessed during this inspection. The requirement is carried forward.) 01/04/07 01/12/06 01/01/07 9. YA24 23(2)(b) 10. 11. YA30 YA32 12. YA38 13. 14. YA39 YA42 The premises must be maintained to ensure a wellmaintained and homely environment for the residents. 23(2)(d) All areas of the home must be kept clean and reasonably decorated. 18(1)(c)(i) Staff must complete induction within twelve weeks of starting employment for the job they are doing. 12(5)(a) Good relationship must be developed between staff and residents to ensure that residents feel safe in the home. 24(1) Residents must be consulted on a regular basis on the way the service is run and developed. 13(4)(c) All COSHH items must be kept locked away. The work surface in the resident’s bedroom must be secured. An application for registration of the manager must be forwarded to the CSCI. 01/04/07 01/12/06 01/02/07 01/12/06 01/12/06 01/12/06 15. YA43 9(2) 01/01/07 Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 27 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 YA35 Good Practice Recommendations The manager should ensure that the induction training is in line with the standards laid down by Skills for Care. Hagley Road DS0000016865.V307271.R01.S.doc Version 5.2 Page 28 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. 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