Inspection on 26/01/06 for Hagley Road

This inspection was carried out on 26th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hagley Road 16/09/09

Hagley Road 23/09/08

Hagley Road 30/04/08

Hagley Road 16/05/07

Hagley Road 17/10/06

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 Unannounced Inspection 26th January 2006 09:30 Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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.V280848.R01.S.doc Version 5.1 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.V280848.R01.S.doc Version 5.1 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 Mrs Kay Marie McIntosh Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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. 16th September 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.V280848.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection over part of a day during January 2006. This was the second of the two statutory visits for 2005/2006. In order to get an overview of the standards assessed this report should be read in conjunction with the report of September 2005. The inspection was carried out on an unannounced basis. There were 10 residents living in the home at the time of the inspection. Three residents and two staff were spoken to during the inspection. What the service does well: What has improved since the last inspection? Most of the requirements made following the last inspection had been attended to. New tables had been purchased for the lounge. Residents were taking more responsibility for attended health appointments and there was more contact with the local community. Brief meetings were taking place with the residents each morning to provide an opportunity for them to raise any issues that had arisen. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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.V280848.R01.S.doc Version 5.1 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): 1, 4 and 5 The home needed to ensure that all residents were enabled to make informed choices about whether to move into the home or not. Residents were given licence agreements so that they knew of any terms and conditions of residence at the home. EVIDENCE: For the new admission to the home there were no records of any preadmission visits to the home, or why there were no pre-admission visits or what else was done to assist the individual to get to know the home and the other residents before moving to the home. All service users had a licence agreement setting out their rights. All residents had received a copy of the statement of purpose and service user guide. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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 and 9 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. EVIDENCE: One resident had transferred from one of the other homes run by the organisation and the assessment and care-planning documentation had been transferred from the other home. This file was sampled and showed evidence of monthly summaries. The Essential Lifestyle Plan (ELP) evidenced that the resident had been involved in drawing it up. The ELP indicated that the staff would deal with post and telephone calls but it was not clear how this information was to be fed back the resident. Records indicated that weight needed to be checked on a ‘regular basis’ but did not state how often, weekly, fortnightly or monthly. The staff were encouraging the resident to prepare a meal on a weekly basis, encouraging the individual to socialise with other residents and on a gradual basis was being assisted to go for a walk. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 10 The action plans needed to include details on how the residents were being encouraged to make choices, how they were encouraged to undertake household tasks. Daily recordings did not evidence the actions that were followed up with the residents after reminding them of the systems in place for getting an alternative meal, for example, on a regular basis one resident’s recordings indicated that the resident was told what they needed to do if they did not want the meal on the menu, however it was not indicated if an alternative meal had been provided. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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 and 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 one of the residents had moved into the flat. Residents were observed to come and go to local facilities including the shops, medical appointments, college. Residents went to the cinema and local pub. Residents were happy that they had gone to the local hotel for their Christmas meal. Some residents were attending local colleges and completing educational courses. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 12 Residents were provided with a varied diet. Residents were encouraged to prepare meals but meals were prepared for those who were unable to do so. Diabetic diets were catered for in the home. There were no records of the actual food eaten by the residents so that it was difficult for anyone to determine whether everyone was receiving a balanced and varied diet apart for those who needed a special diet. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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 and 19 Residents were supported with personal care if needed and their physical and mental heath needs were met. EVIDENCE: The service users were independent and required very little assistance to meet their personal care needs. Prompting was provided where required. One resident had moved on since the last inspection to supported living and another resident had moved into the flat to start some independence training. The residents stated that they were seen regularly by health professionals and attended clinics where required. Residents said that they came to the office for their medication. There was evidence that a resident who had had a recent bereavement was being supported with the emotions being felt in the home. Residents who had close friendships were being helped to access some time alone. Medication was not inspected at this inspection but the system was well managed at the previous inspection. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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): 22 and 23 The residents were listened to and protected from harm by the home’s policies and procedures and staff training. EVIDENCE: There had been no complaints about the home made either to the home or to the CSCI. There were adequate policies in place for residents and visitors to raise concerns as they arose. The adult protection procedures were not assessed but the inspector was aware that they were the same as other homes run by the organisation in Birmingham and this policy was up for review in the near future. The organisation needed to ensure that staff were clear of what actions they needed to take in the event of an allegation or suspicion of abuse and that they were in line with the multi-agency guidelines. One allegation of abuse had been made since the last inspection and handled appropriately by the home. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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): 24,25,28 and 30 The accommodation was homely and met the needs of the residents. EVIDENCE: The home was suitable for the needs of the residents and well placed in the local community and accessible to community facilities. There continued to be a programme of decoration on going in the home. New tables had been bought for the lounge. The lounge and dining room were homely and comfortable. The lounge was used as a smoking area for both staff and residents. There was no lounge area available for staff, residents or visitors who were non-smokers. The organisation were in negotiations with the Landlords to see if this issue could be addressed. There were snack-making facilities available in the dining area. Two bedroom carpets needed to be replaced. The residents stated they were happy with their bedrooms. Bedrooms were personalised to the residents liking and all were lockable. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 16 There were sufficient bathing facilities in the home to meet the needs of the residents. The residents were mobile and needed few adaptations to assist them around the home. There were laundry facilities available to staff and residents. The home was found to be clean and odour free. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 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): 31,34,35 and 36 Adequate staffing levels were being maintained and support was being provided by a well-trained staff group. EVIDENCE: The staffing levels continued to meet the needs of the residents. There were three members of staff on duty during the day, one sleeping in staff at night, and a domestic assistant for four hours a day during the week. The home was using some agency staff, as there were some vacancies in the home. These consisted of a full time care officer, part time care officer and part time care assistant. The staff were aware of their roles and worked well together. Two staff records were sampled. The home had good recruitment processes in place however, for a member of staff who had transferred from another home the personnel file had not been made available to the manager. This member of staff, although an employee of the organisation for a number of years, needed to have received a documented induction into the workings of this home. All the appropriate employment checks were being undertaken. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 18 The home continued to provide a good training programme for staff ensuring that appropriately trained and supervised staff supported residents. Some of the training undertaken during 2005 included journey to recovery, voices, individuality of support, medication and first aid. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 19 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, 38,39 and 42 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 was appropriately qualified to manage the home. During the inspection process she showed she had the knowledge and skills to support the residents. There was an open and inclusive atmosphere in the home as evidenced by the residents coming to the office to find out who was in the home and raising their concerns about other residents who they felt were not getting their needs met. Confidentiality was maintained at the same times as reassuring the residents. There was documented evidence that concerns raised by the residents were discussed at residents meetings. There were brief residents meeting each Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 20 morning to ensure that residents could raise any issues as they arose and that they felt that even minor things would be looked at straight away. Health and safety matters were well managed in the home. Weekly fire alarm and monthly emergency lighting tests were being carried out. There were regular fire drills. It was noted however that two fire doors in the building did not close appropriately onto the rebates and needed to be attended to. Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 21 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 2 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 3 3 X X 2 X Hagley Road DS0000016865.V280848.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA4 Regulation 12(1)(a) Requirement 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. Action plans and ELP’s must clearly identify how the goals are to be achieved. Daily recordings must indicate any follow up actions taken when advising the residents about the systems in the home. A record must be kept of the food eaten by each resident. (Previous timescale of 01/11/05 not met.) 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. The carpets discussed at the inspection must be replaced. The manager must ensure that the personnel file of staff transferring from other homes is made available to them before the staff transfer to ensure that they are suitable for the home. DS0000016865.V280848.R01.S.doc Timescale for action 01/04/06 2. 3. YA6 YA7 15(1) 12(1)(a) 01/04/06 01/04/06 4. YA17 17(2) Sch4(13 13(6) 01/04/06 5. YA23 01/04/06 6. 7. YA25 YA34 16(2)(c) 18(1)(a) 01/06/06 01/04/06 Hagley Road Version 5.1 Page 23 8. YA42 23(4)(c)(i) The manager must ensure that all fire doors close appropriately into the rebate. 14/03/06 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.V280848.R01.S.doc Version 5.1 Page 24 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.V280848.R01.S.doc Version 5.1 Page 25 - 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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