Inspection on 20/11/06 for 22 Hallewell Road

This inspection was carried out on 20th November 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22 Hallewell Road 29/08/07

22 Hallewell Road 24/01/06

22 Hallewell Road 06/06/05

22 Hallewell Road 22/11/04

22 Hallewell Road 02/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Hallewell Road, 22 Edgbaston Birmingham West Midlands B16 0LR Lead Inspector Peter Dawson Key Unannounced Inspection 20th November 2006 09:00 Hallewell Road, 22 DS0000017074.V300858.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 Hallewell Road, 22 DS0000017074.V300858.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. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hallewell Road, 22 Address Edgbaston Birmingham West Midlands B16 0LR 0121 455 8269 0121 454 5177 martomoi@blueyonder.co.uk 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) Mrs Marcella Marie Higgins Mrs Marcella Marie Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Residents must be aged under 65 years One named service user with additional physical disabilities may be resident at the home. One exisiting named person can be accommodated and cared for in this home for reason of mental health needs subject to appropriate review of the home’s suitability. The home can continue to accommodate two named service users who are over 65 years. 24th January 2006 Date of last inspection Brief Description of the Service: 22, Hallewell is a three-bedroom home for adults who have a learning difficulty. The home is a three storey building in a quiet residential road in Edgbaston, Birmingham. The home is within walking distance of shops, places of worship, a park, pubs, restaurants and a selection of bus routes providing access to the city centre. The registered premises comprises of two lounges, a kitchen with a dining area, WC, a separate laundry and a conservatory area. The three service users each have their own bedroom on the first floor. There is a bathroom and a separate toilet on the first floor. The registered person and her partner live on the premises on the third floor. The home is furnished and decorated to a high standard and is reflective of a family type domestic dwelling. To the rear of the home is a garden with lawned areas, a patio and at the top of the grounds there are three wooden buildings in the style of a western town to provide entertainment on the country and western theme for those who live and work at the home. The home is also used as a day facility for three people on most days of the week except Saturdays. Two people currently use this facility. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day between the hours of 10 a.m. – 5.00 pm. A pre-inspection questionnaire was received by the Commission prior to the inspection and forms part of the information in this report. Written feedback was not received from residents or relatives but was received from a Psychiatrist and the Practice Manager at the GP practice. Both spoke highly about the care provided at Hallewell Road and the cooperation of staff. All parts of the environment were inspected including residents’ bedrooms (with their permission) and all the communal areas. All 3 residents were seen and spoken to together and separately and also the two people attending day care. The Manager and 4 members of staff were seen and spoken to. Records relating to the inspection process were seen including residents’ personal records, staff files and rota, fire records, policies/procedures, medication records and records relating to equipment. What the service does well: There is a good standard environment that is well maintained. Furnishings, fitting and equipment are to a good standard. The home is furnished along domestic lines and replicates a large Victorian family home. There are friendly relationships with neighbours, one called to check who the “stranger” was – ensuring the well-being of people in the home. The small staff group is static and provide a professional but close, warm atmosphere with detailed knowledge of resident need and important continuity. Good engagement between staff and residents was clear. Residents listened to and treated with respect. Care planning and health care records showed attention to the detail of care need and clearly identified actions required by staff to meet those needs. Residents seemed very happy and relaxed. They confirmed that they were “happy” at Hallewell Road and spoke equally enthusiastically about going out to day centres regularly and visiting pubs, restaurants and socialising in the community. They are always escorted by staff and transport is constantly available for any purpose. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 6 Two people attend for day care and they have established warm relationships with residents and staff. The home operates as a family unit with Manager and partner being constantly available and living on the premises. They live as an integral part of the family unit. At the time of the last inspection 16 requirements were made, the majority relating to documentation. With the exception of 1 all have been fully addressed – confirmation of the providers commitment to improving the service and compliance with regulatory requirements. What has improved since the last inspection? The service users guide/statement of purpose have been updated and statement of terms and conditions included. Care plans have been re-written and expanded and daily notes for residents changed in format to include greater detail of daily events in the living situation. Risk assessments have been reviewed and aspects of detail added as required. Health care records for each resident have also been re-written and now include a chronological list of all interventions by health care professionals with outcomes. Changes to Medication Administration Records have been made to improve clarity and safety. The complaints procedure has been updated. There has been staff training in the Protection of Vulnerable Adults There is now a training matrix for all staff members, easily identifying training undertaken or required. An additional policy/procedure has been provided as required, all procedures are now in place. Daily temperatures of fridges/freezers are now kept as part of food safety. A window restrictor has been fitted to a first floor bedroom window following a requirement. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 7 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. Hallewell Road, 22 DS0000017074.V300858.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 Hallewell Road, 22 DS0000017074.V300858.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The quality of this outcome area is good. This judgement is made using available evidence and a visit to the service. There is adequate information available to inform choice of home. Contracts state clearly the service provided at the home. EVIDENCE: There is a statement of purpose and service users guide in the home available for visitors and there is a copy in each resident’s bedroom. Following requirements of the last report these documents have been updated to include sizes of rooms and the fact that nursing is not provided in the home. A service is provided by the district nursing service. A requirement was made to provide a standard form of contract with between the home and resident and to confirm that a holiday will be provided. The requirements have been met with contracts provided including the statement of a holiday being provided in the contract price. In fact a holiday is always provided for the residents each year, but this has now been formalised in the service users guide. The resident group remains the same as the last inspection. The last admission to the home was 9 years ago. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 10 There have been recent amendments to registration to cover the needs of the current resident group. For name residents the additional categories are one person with a physical disability, one with mental health needs and two who are over 65 years of age. The categories adequately cover the current resident group. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 The quality of this outcome area is good. This judgement is made using available evidence and a visit to the service. Care planning and daily recording of information has improved and is satisfactory. Decision making, participation and support from staff is evidenced and satisfactory. EVIDENCE: A requirement was made at the time of the last inspection to provide more details in care plans stating how needs were to be met and to give more details of the daily routines of residents. These matters have been adequately addressed. All care plans have been rewritten, updated and expanded to include more detailed information about needs identified and the actions to be taken to meet those needs. Considerable work has been done in this area by the Manager and the result is good, improved care planning information. There is a now a separate daily diary for each resident which includes details of activities and events concerning each person in more detail. There was previously a daily record for Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 12 each resident of food provided and brief statement of activity, but this can now be incorporated into the new documents. Two care plans were seen in detail and included adequate information concerning the personal interventions required to assist residents and there was an adequate record of health care needs and interventions. Monthly residents meetings are held and are minuted. A recommendation of the last report was to include more information about residents’ choices and what actions are taken when requests for changes are made. The minutes were seen and provided adequate information and detailed recording of matters discussed. Suggestions made included questions about hair care, purchase of Xmas presents and one to “improve my dancing”. All were addressed with actions to be taken. It was recorded that one resident said, “no improvements needed – I am a happy man” During the inspection residents were seen to be making choices about food, activity and when and where to socialise. There was evidence of residents being supported in visiting relatives, receiving visitors in the home and all were involved in the daily life as it happened in the home. All residents have adequate verbal skills and staff seen to assist or interpret where necessary for clarification, residents clearly confirming and responding to those prompts. The views of residents were seen solicited by staff as they talked and interacted in the lounge area. Residents were encouraged to verbalise their views and opinions. Risk assessments were seen and were satisfactory and reviewed on a monthly basis. These are an integral part of care planning information and any restrictions recorded with reasons e.g. residents do not go out alone, the reasons for this are recorded and residents aware of the reasons and outcomes of risk assessments. Information relating to residents is stored securely in the office area of the home and available only to residents and authorised persons. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 The quality of this outcome area is good. This judgement is made using available evidence and a visit to the service. Residents participate in activities provided by the service and other providers, affording them a meaningful lifestyle. There are positive relationships between residents and staff and the home replicates a family domestic setting. There is good food provision. EVIDENCE: This is a well established group which operates as a family unit. The 3 residents have been at the home for 12, 12 and 10 years respectively. Additionally the home provides a day service for up to 3 people, two have attended over a period of several years. The group interact well and there are established relationships between residents. All 3 residents attended day centres until recently when one ceased attending following a hospital admission and needs not being met at the day centre. There is currently a re-assessment of this persons needs to provide 1:1 care at specific times. One resident attends Evergreens day service 5 days another Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 14 attends college courses 5 days at Moseley day services, she enjoys going very much and complains when the service closes annually for holidays. At the time of this inspection she was at home with some congestion of her chest - she has heart condition monitored by Consultant and also has to be closely monitored in the home. She was anxious to return to day services the following day. She has a “boyfriend” at the centre and supported in this friendship. The 2 people attending the home for day care attend 5 days and this includes some days at weekends. Both have mental health needs and the Manager has considerable experience in providing support to people with those needs having been long involved in a hospital support discharge service. One of the residents also has mental health needs and registration category has been granted for that purpose. At the time of this unannounced inspection the 3 residents were at home and later joined by the 2 day care people, one transported in car by staff. There were at one point 5 staff in the home, including one who works 4 hours per week to engage residents in activities/occupation – she was formerly the activities worker. Residents spoke openly about their life at Hallewell Road. They engaged well with all staff and made a contribution to the inspection process. They were observed choosing food and eating lunch, were later engaged in 1:1 conversation with staff and 2 playing dominoes in the lounge as part of the socialisation and discussion process. A resident was knitting whilst involved in the general conversation, another watching favourite detective films on TV. At one point during the afternoon three staff on duty (apart from Manager and partner) were sitting in the lounge with residents enjoying conversation, promoting discussion and laughing often. Residents were seen to be treated with respect and encouragement. Apart from day centre attendance residents go out into the community for meals to pubs, restaurants etc. The owners and residents are interested and involved in country & western music and some go line-dancing, others enjoy the social benefits. They go to social events and festivals. A resident showed her recently purchased “dance dress” (Western-style) that she is clearly proud of. There is a Western-style saloon wooden building in the garden area, used often in the summer months. All residents have some family contact and visitors. One spends a day each weekend with her sister and goes out for the day. Another is taken to briefly see relatives each week after going out for a meal (there are some restrictions due to vulnerability which is well documented). The other resident has family and other visitors. Two people with whom he has established friendships at day services come regularly for a meal and spend time in the resident’s bedroom where he entertains them. One person goes to church each week that she is totally committed to and enjoys – taken by staff. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 15 All residents have an annual holiday funded by the providers – they just need spending money. The providers have a caravan which is regularly used, residents spoke positively about their holidays. Although annual holidays have always been provided, this is now included in the homes contracts as part of the service offered by the home. Transport is readily available the 2 providers have cars used extensively for appointments, outings etc. There is no charge to residents at all for this service. Residents will pay for taxis if they are required e.g. to supplement transport when going out as a group – one resident requires wheelchair and special taxi transport sometimes needed. These costs are shared between residents and there are no restrictions upon transport for any purpose. Observations portrayed a picture of family life in the home, with a relaxed atmosphere and natural relationships between staff and residents. The providers live on site on the second floor of the home and are available at all times. The mid-day meal comprised choice of main dish (both were cooked). Residents said they liked the food and could have “what they wanted”. Choice of sweet was provided and there were bowls of fruit on the dining table. One resident seen to have prepared banana with mid-morning meal. The Manager is committed to healthy eating and diet providing wholesome food without the many additives usually found. The meal was cooked by a member of staff and enjoyed also by the providers and inspector. The dining area is bright, pleasant and has an attractively laid table with good quality linen/cutlery (lace tablecloth/table decorations etc). Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality of this outcome is adequate This judgement is made using available evidence and a visit to the service. Updating of moving & handling training is required. The physical and psychological needs of residents are met. The basic medication system is safe and there is a good record of health care management and recording. EVIDENCE: Residents are assisted with personal care as required by staff. This is clearly documented in care planning information. Two residents require oversight only in relation to personal hygiene. One resident does require assistance with mobility. He has a left residual weakness following former stroke. He has recently been in hospital and results of scans are awaited. A specialist nurse is to visit him at home shortly and the physiotherapist has defined he has no further immediate needs. The home are currently seeking a re-assessment of his needs as he is no longer able to attend day service centre. His personal needs are inconsistent requiring assistance to transfer or move at varying times. He needs assistance with washing and dressing and bathing. He did say that he was happy with the personal care that he received from staff and “they always help me when I need them to”. A moving and handling risk assessment has been reviewed in the light of these changes. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 17 Staff require updated training in relation to moving & handling and that is referred to elsewhere in this report. Examination of residents’ records relating to health care showed that changes had been made following a previous requirement for each person to have an individual health care action plan. This information was previously available in brief form and has now been extended to give a chronological record of all inputs by health care professionals. Entries show the outcomes of health checks made. The revised information is quite adequate. Two care plans were examined and health care information was seen to be good. All are subject to Waterlow assessment and had been recorded as low risk –there are no pressure area issues at this time. Two residents have diabetes, one has regular daily blood sugar levels checked with machine by staff and are recorded. Any fluctuations referred to the GP. All residents have regular health care checks – two by the GP with nurse visiting the home and another in conjunction with Consultant Heart Specialist who monitors her closely. One resident has epilepsy controlled with medication but occasional seizures, the last being 1 year ago. There is a protocol in place for staff defining the action to be taken, timescales etc. All residents are weighed monthly and weights recorded. CPN, Physiotherapist, Dentist, Optician, GP, Psychiatrist and Consultant Surgeon have all been involved with residents during the past year. Health care records now record these interventions which are easily monitored. A Psychiatrist (Associate Specialist) and the GP in written feedback to the Commission both stated that there was close and positive working with staff and that they were satisfied with the care provided for their patients at Hallewell Road. Medication is supplied to the home by local pharmacy a good service is reported. All staff administering medication have undergone certificated training with Boots Chemists. The Manager and partner are currently studying further course in Safe Handling of Medicines at Solihull College, in efforts to further extend their knowledge. Two requirements relating to medication of the last report have been satisfactory addressed. On this visit MAR sheets were inspected, have been modified as required in the last report with a count of medication included. In one instance it was noted that medication had been given but not signed on the MAR sheet, this must be done at the point of administration. The medication system in place presented a well documented and safe system. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality of this outcome area is good. This judgement is made using available evidence and a visit to the service. The complaints procedure is readily available and there are external opportunities to report concerns. Procedures protect residents from abuse. EVIDENCE: No complaints have been received by the service or the Commission since the last report. There is a clear and concise complaints procedure in place which has been amended since the last inspection to include details of how to contact CSCI and the statement that no-one will be victimised for making a complaint. All residents have basic communication skills and all have relatives/visitors who they can talk to about any concerns. Additionally all have attended day service centres allowing a further opportunity to express any concerns. Advocates are not required for these purposes at this time. The procedure is available to visitors and is part of the service users guide, a copy of which is available to all residents in their bedrooms. A requirement for staff to undertake training in Adult Protection has been met. Three staff have attended a course since the last inspection. Discussions with staff showed they have an understanding of the broad definitions of abuse and the procedures for reporting suspected or actual abuse. The Adult Protection Procedure in the home has been amended to state that CSCI must be notified of any incidents of suspected abuse. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 The quality of this outcome area is adequate. This judgement is made using available evidence and a visit to the service. There is a comfortable, homely environment that is well maintained and safe. Bedrooms reflect individuality and are adequately furnished and clean. Communal areas are adequate and used effectively for living and activities. Plans to install new shower facility are needed to meet the needs of a resident with a physical disability. EVIDENCE: This is a large Victorian terraced house with accommodation on 3 floors. The property is well maintained both internally and externally. There is a large patio and garden area to the rear easily accessed from the French windows in the rear lounge and rear door. The premises are not recognisable as a home. On the ground floor there are 2 lounges, large kitchen/dining area, food/storage area, office and bathroom with toilet. The residents 3 bedrooms are located on the first floor with access by stairs or stair-lift for resident unable to use the stairs. The bedrooms are of varying size and individualistic in presentation. All are well furnished with adequate wardrobe/drawers for storage, all have wash-hand basin and they are all well Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 20 personalised with TV/DVD/Music facilities etc. There are 2 double power points in each bedroom to service equipment used. Photographs, soft toys and personal memorabilia adorn the walls. There is a separate bathroom (unassisted) and separate toilet on this floor. The rear bedroom has recently had the French windows replaced with double glazed units with doors opening out onto the roof area. This is a fire exit from the first floor. The Managers personal accommodation is located on the second floor. One resident has a physical disability and requires total assistance whilst bathing. He presently bathes in the ground floor bathroom (with over-bath shower) but there is no assisted facility. There are plans to re-design/rebuild the bathroom to incorporate bath, walk-in shower and toilet. He accesses his bedroom on the first floor by means of the stair-lift. A risk assessment is provided relating to a radiator in a bedroom which cannot be fitted with a cover. A requirement to fit a restrictor on a first floor bedroom window has been completed. All areas of the home were found to be clean and hygienic on this visit. There are 10 hours per week domestic assistance. Residents are not involved in cleaning their bedrooms or communal areas. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 21 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, 32, 33, 34, 35, 36 The quality of this outcome area is good. This judgement is made using available evidence and a visit to the service. A small but static staff group providing a high level of support to residents with continuity of care. Training is generally good, although first aid and moving & handling training are required at this time. EVIDENCE: No new staff have been appointed since the last inspection, when staffing records were inspected. One staff file was seen on this visit and had all required documents and information. A requirement to provide a staff training matrix was made at the last inspection. This has been done – there is a personal training matrix for all staff. The home is staffed by the Manager who works full-time and states she is available 24 hours per day. She lives on the premises. Her partner works similarly and is engaged in administration, transport and some care duties. Additionally there are 2 full-time staff (both worked 60 hours the previous week), an activities worker who works 12 hours per week and another person who works 4 hours per week providing activities with residents. Additionally a Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 22 domestic assistant is employed 10 hours per week. Staff are involved in preparing food. The number of weekly hours is difficult to define as the home is run as a large family unit. The week before the inspection there were a total of 142 hours from the 4 staff plus the Manager and partner who also work full time, live in and therefore cover staff sleeping-in duties. The staffing levels are adequate for the perceived dependency levels of the 3 residents. Excluding the Manager two staff have completed NVQ3 and one is due to commence NVQ2 training soon. The target for the required minimum number of NVQ trained staff is met. Staff training is required in First Aid and Moving & Handling. Staff roles are clear – the home operates as a family unit and staff are required to have generic skills. Care staff spoken to and observed providing care to residents during the inspection showed thorough knowledge of the needs of residents, listened to them and were respectful and supportive in their interactions. Residents’ opinions were sought and they were encouraged to express their views. Regular supervision is in place. Records seen. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 23 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, 40, 41, 42 The quality of this outcome is is adequate. This judgement is made using available evidence and a visit to the service. The home is well managed and residents listened to. Policies and procedures are in place. Requirements are made in relation to fire safety and staff training. EVIDENCE: The Manager has considerable experience in providing a service for this resident group. The home has operated under her leadership for the past 12 years (2 current people being resident since that time). She has also experience in providing a service to people with special needs including those with mental health needs. She has completed the NVQ4 in Management and the Registered Managers Award. The Manager and her partner work full-time hands-on in the home leading the care in a positive way. The home is run along domestic lines and replicates a large busy but happy family unit. There are positive bonds between staff and Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 24 residents. Other staff seen have 2 years service in the home and have similar qualities and commitment to residents. There is an open management approach in the home. There is a relaxed and open atmosphere in the home and residents speak openly about their life at Hallewell Road. The Manager carries out her own Quality Assurance of the service. This includes feedback from residents, relatives and staff. There is a range of policies/procedures available to inform practice. Some have been updated since the last inspection. All six requirements made under these outcomes at the time of the last inspection have been satisfactorily addressed. Fire records were inspected and all drills, checks and servicing of equipment had been carried out as required. The Fire risk assessment was seen in date and satisfactory. There is a fire exit door from a bedroom on the first floor. In this bedroom new double-glazed French windows have been fitted. The keys to the two locks are left in the bathroom area (resident would remove from door). Upon collection of the keys it was not possible to know which key opened which door it was impossible to unlock the door swiftly. It was agreed that a key could be left in the bathroom but another key should be located above the door and the fire exit door clearly marked. This must be included in the fire safety instructions and all staff aware. All residents sleep on the first floor and the providers on the second floor. In the event of a night fire the providers would come downstairs and take the 3 residents through the fire door mentioned above to safety. However, one of the residents has a disability and needs help with mobility. He uses a wheelchair for distances and the Manager will ensure that a wheelchair is always available on the first floor for the purposes of transporting that resident safely through the exit in the event of fire. This will also be recorded in the fire instructions. Discussion revealed that the fixed telephone (portable handset) is located on the ground floor. It was agreed that at nigh- time a telephone must be available to the providers on the second floor to summon help immediately in the event of fire. This will be done. The Manager agreed that residents will be involved in a fire drill during the day to cover the situations described above. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 25 Staff required updated training in Moving & Handling and also in First Aid. Courses have been arranged for these on 30th and 28th November respectively. Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 26 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 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 23 3 X 3 X 3 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 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 DS0000017074.V300858.R01.S.doc LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 17 3 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hallewell Road, 22 Score 3 3 2 X 3 3 3 3 3 2 X Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Medication must be signed for at the point of administration. Updated training required for staff in First Aid and Moving & Handling Fire exit door on first floor to be clearly marked and key located above door. Wheelchair to be available on first floor at night time. Ensure phone is available on first and second floor at night time. Timescale for action 21/11/06 2 3 YA42 YA42 13(4)(5) 18(1)(c) 23(4)(a) (b) 31/12/06 21/11/06 4 YA42 23(4) 21/11/06 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 Hallewell Road, 22 DS0000017074.V300858.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: 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 Hallewell Road, 22 DS0000017074.V300858.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!