Inspection on 24/01/06 for 22 Hallewell Road

This inspection was carried out on 24th January 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 16 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 20/11/06

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 Joe O`Connor Unannounced Inspection 24th January 2006 10:45 Hallewell Road, 22 DS0000017074.V275915.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 Hallewell Road, 22 DS0000017074.V275915.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. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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.V275915.R01.S.doc Version 5.1 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 existing 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. 6 June 2005 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 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.V275915.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a day. The Inspector had opportunity to talk to two service users along with two members of staff and care practices were observed. A limited tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined. The Inspector had opportunity to talk to the Registered Manager. For a full overview of the service this report should be read with the one of the unannounced inspection of 6 June 2005. What the service does well: Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not known. The service provides service users with a clean, tidy and homely environment, which they appreciate. Service users were observed to receive friendly and professional support from staff at the time of this inspection. They were dressed in clothing that reflected their age and lifestyle. The manager is very committed and takes great care in ensuring the service users needs and wishes are addressed as a priority. She is very welcoming and it was apparent during the inspection the manager is keen to improve practice for the benefit of the service users. Observations during mealtimes found that service users receive a healthy and varied choice of meals. At the time of this inspection the service users had a lunch choice of chicken vegetables and potatoes or lamb chops. The meal was sampled and it was well cooked and very tasty. The service users were observed to enjoy the meal with additional helpings being offered by staff. It is good to see that the manager provides the service users with a range of organic food and drink with fresh ingredients. An examination of the care records for the service users indicated they were receiving appropriate support with their health care and had checks with their GP, Optician, and Chiropodist. Two service users commented they were happy with the support they receive and one pointed to one member of staff who she said was very nice. Another service user who has day care during the week said she enjoyed coming to the home and was able to have a drink at anytime. Another service user spoke about his interests in what Birmingham was like in the old days. The service users are involved in activities that suit their age and lifestyle. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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.V275915.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 Hallewell Road, 22 DS0000017074.V275915.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, 3, 5 Prospective service users have information about the service, which will require amending to reflect in full the requirements of the National Minimum Standards. Service users needs are currently met with appropriate and positive support provided by staff. Service users do not have their own individual statement of terms and conditions to inform them what they are paying for. EVIDENCE: There is a Statement of Purpose and Service User Guide that will need amending to make reference to whether or not the service provides nursing care, the sizes of the rooms and which aspects of the physical environment does the service not meet the National Minimum Standards. It was noted each service user had a copy of these documents in their bedrooms. When sampling two service users care records it was noted that contracts were in place provided by Birmingham Social Care & Health. However no evidence could be seen confirming whether service users had their own statement of terms and conditions informing them what they were contributing towards their care. The Service User Guide should have a standard form of contract. At the time of this inspection service users were observed to be dressed appropriately for the climate of the day and the atmosphere was relaxed and friendly. One service user commented she was a little said about not being able to going to her day centre as she was recovering from chickenpox. Another service user was keen to talk about his interest in what Birmingham Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 9 was like in the past and when he worked in the old Birmingham Market. Another service user said she was happy in her accommodation and liked her bedroom. Observations at the time of this inspection found staff speaking to service users in a respectful and friendly manner. Since the last inspection the manager has applied for a variation to her registration in order to continue providing care for one service user aged over seventy and another who has a physical disability. This was approved by the CSCI although the manager stated she would no longer take people on who had problems with their mobility. There have been no new admissions to the service since the last inspection. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Service users have individual care plans that require further development in setting out how their needs are to be addressed. Service users are encouraged and supported to make decisions about their lives. Service users have risk assessments that describe how any identified risk should be managed. EVIDENCE: Two service users care records were sampled and these contained care plans, which set out the identified needs of the service users. However, it was noted work was needed to provide more detail as to how the identified needs were to be addressed. For example one care plan seen referred to a service user having diabetes but did not provide specific information as to how this should be managed e.g. how often should their blood levels be tested and by home. The care plans also needed more detail about the service users’ typical daily routine such their preferred time of getting up and going to bed, and what aspects of personal care could the service users manage. When talking to the service users it was evident they have opportunities to make about decisions about their lives. There are monthly meetings where the service users can talk about future activities and meals. The minutes for these would benefit in having more detail to show how any choices were made and Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 11 indicate any action to be taken if the service users made any requests for new activities. When sampling service users care records there was written evidence showing that the manager had consulted with one of the service users as to which member of her family she preferred to manage her financial affairs. When interviewing two members of staff they stated that the service users could choose what they wanted to do and what they wanted to eat. Each service user has a risk assessment that indicated how they should be supported in the building and these had been reviewed prior to this inspection. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Service users participate in activities provided by the service and other organisations affording them a meaningful lifestyle. Service users are not subjected to any unnecessary restrictions on their daily routines. Service users maintain positive relationships with staff and their relatives. Service users are provided with a varied and healthy range of meals promoting their nutritional well being. EVIDENCE: Two service users stated they attended a daycentre during the week which they enjoyed going to. One service user commented that she enjoys visiting Cannon Hill Park and plays Bingo on a Friday. She also enjoys football and spoke about her Christmas present of Match of The Day DVD. Another service user said she goes to the local pub for lunch, as do the others. She also enjoys doing knitting and showed an example of what she was working on. The manager showed photographs of the service users involved going to a country and music festival last summer and having a Halloween party. The service users appeared really happy and were dressed very smartly for the event. One service user goes to church every Sunday and enjoys this a great deal. Staff commented how involved the service user is in singing along with the Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 13 congregation. The service users are able to pursue their own leisure interests. One service user enjoys watching detective programmes and films. There is a karaoke machine and in the lounge SKY TV is available for all of the service users and they also have access to their own TV and stereo equipment. It was noted the daily recording of service users needed more detail around how service users spent their leisure time during the day and evening and where exactly did they travel to. The manager showed a format, which included sections where staff were to encourage service users to talk about current events on the news and take part in a quiz about those events. The service does have its own day service and there is a member of staff responsible in providing activities such as Keep fit along with various board games. Observations at the time of this inspection indicated this is very much the service users home and there appeared to be no unnecessary restrictions apparent. When asked about any house rules one service user commented that she was allowed to smoke but could only do this outside. Another service user commented that she does cookery at her centre but would like to have a go at cooking in the home. There is a good relationship between the staff members and the service users and when examining the service users records there was evidence they were able to maintain contact with their relatives by telephone or during visits to the service. An examination of service users records indicated confirmed they were eating a varied and nutritious meal. Observations were made of service users having lunch. There were two main choices for lunch. Roast chicken drumsticks with mashed potato and vegetables or lamb chops. Staff were observed to ask service users what they would like and additional helpings were offered. The meal was sampled which was well presented and very tasty. One service user pointed to a member of staff and said, “She is a very good cook”. The manager stated that the majority of the ingredients used for meals are organic including tea and coffee that is also de-caffeinated. An examination of the food cupboards and refrigerator were well stocked. The service users were offered a choice of deserts including cakes and yoghurts. It was evident staff were aware certain dietary requirements such as those who have diabetes that is partly diet controlled. Service users were drinking filtered water, which the manager says has been beneficial to their health. The atmosphere at lunchtime was relaxed with staff giving time for service users to finish their meals. It was evident they were enjoying what had been prepared as there was nothing left on their plates! In discussion with the manager she was currently competing an accredited training course in nutrition at Bournville College. Discussion with staff and the manager found that the service users were involved in the food shopping. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Improvements are required with regard to manual handling practices ensuring the safe transfer and movement of service users. Service users healthcare is appropriately managed by staff promoting good health with some improvements needed. Service users have been consulted about their final wishes in the event of a serious illness or death. Medication management for the service users is good but some improvements are required in the recording of medication details. EVIDENCE: An examination of service users daily records indicated there was some evidence to confirm where service users had assistance with their personal care. Two staff interviewed stated service users would choose when they got up or go to bed and there were no set times for a bath or shower. Each service user has a manual handling assessment and it was noted some minor amendments were required such as whether any manual handling requirements were needed for bathing although one sampled did refer to action to be taken for one service user in the event of a fall. At the time of this inspection observations were made of staff assisting a service user who had a stroke with a right sided weakness, to stand up. One member of staff was observed to be holding on to the service user’s weak arm, which was inappropriate. This was discussed with the staff member concerned and the manager who both acknowledged this should not have happened and stated Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 15 that usually the service user was independent in standing up when transferring. An examination of service users records confirmed they had contact with healthcare professionals including GP, Dentist, Optician and Chiropodist. One service user stated she has visits from a “foot lady” (chiropodist) and was looking forward to getting a new pair of spectacles. Another service user has regular blood tests as part of her monitoring for diabetes had recently attended a diabetic clinic. Further examination of the records showed that warterlow assessments and those covering nutrition had recently been reviewed. Discussion with the manager identified the need for each service user to have an individual health action plan in line with the Department of Health’s Valuing People Guidelines. Information about this was forwarded to the manager at the time of writing of this report. Since the last inspection the manager provided evidence that she had consulted with the service users who they would like to be involved in their final wishes. These were signed by the service users and referred to specific family members being contacted and nominated to deal with their affairs in the event of their death. The management of medication was good at the time of this inspection and it was stored securely. However, when examining one of the Medicines Administration Records it was noted that one service user who was on different tablets had their medication details printed in one entry on the MAR sheet. Photocopies of the prescriptions are stored separately but it is good practice to ensure these are attached to the MAR sheets to check for accuracy prior to dispensing. Photographs of the service users must also be in place. An examination of staff records indicated the manager and her partner had completed medication training provided Boots Pharmacy. Discussion followed advising the manager to pursue accredited medication training in the Safe Handling of Medicines course provided by Solihull College, which she gave a commitment to access this course. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users have access to a complaints procedure, but amendments are required. Service users’ welfare is protected but the prevention of abuse of vulnerable training must be undertaken. EVIDENCE: Neither the service nor the CSCI have received any complaints since the last inspection. There is a complaints procedure in place but this will need amending to include information such as the CSCI can be contacted at anytime during the complaints process and that no one will be victimised for making a complaint. One service user stated she would go to the manager if she had any problems. The manager undertakes a quality audit through the use of anonymous satisfaction surveys for service users, relatives and staff. There is an adult protection policy and procedure but this will need significant development and include the role of the CSCI and refer to the multi agency adult protection guidelines published by Birmingham Social Care & Health, of which the manager had obtained a new copy. An examination of staff training records found no evidence that adult protection training had been in place. In discussion with the manager she acknowledged this needed to be done and would look at various training providers for a suitable training package. It was suggested to the manager that as a start she goes through the multi agency guidelines with staff at their next staff meeting and explain the purpose of the guidelines and where they can be accessed. Two staff interviewed gave satisfactory responses to questions around the issues of adult protection and were aware of the need to inform the CSCI if such incidents of suspected abuse were to occur. Both stated they would able to challenge any poor practice. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 17 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, 26, 27, 28, 29, 30 Service users live in premises that are clean, tidy providing a warm homely environment. Service users well being is maintained with staff observing appropriate infection control practices. Service users have access to communal space that is comfortable and homely. Service users bedrooms are individually furnished to their own lifestyle and tastes. Service users have access to bathing and toilet facilities with suitable privacy locks. There is specialist equipment in place to assist service users with mobility difficulties access the first floor of the building. EVIDENCE: A tour of the premises was undertaken and the building was found to be clean, tidy and well maintained. The manager stated a new gas boiler had been installed since the last inspection. The premises have a separate office and laundry area. Three bedrooms were viewed and it was noted that each of them had a wash hand basin and most of the furniture required within the National Minimum Standards. There was evidence service users had their own possessions including photographs, ornaments, TV stereo, DVD and video players. It was noted that not all of the service users’ bedrooms had two double electrical sockets and consideration should be given to rectifying this particularly should Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 18 any of the bedrooms become vacant. There are toilet and bathing facilities available on the ground and first floor. The manager had addressed a requirement from the previous inspection to fit suitable locks on the bathroom and toilet floors. A stair lift is place to assist one service user who has mobility difficulties to access the first floor. In discussion with the manager she spoke of her wish to eventually re-furbish the ground floor bathing facility and make it more accessible. However, she was concerned that any attempt to do this would create difficulties for one service user who could not cope with any disruption to his routine. There is a separate laundry facility and there is a procedure in place as to how any soiled items should be transferred through the premises. Staff were observed to wear protective aprons when preparing meals. There are procedures in place for the control of infection. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Service users are supported by qualified staff that provide positive and friendly support and know their individual needs. Service users receive continuity of care with appropriate levels of staffing. Service users benefit form staff that receive training to undertake their duties but improvements are required in planning and recording future training needs. Staff receives appropriate levels of supervision to undertake their duties effectively. Service users interests are protected with appropriate recruitment practices. EVIDENCE: Two members of staff were interviewed and they demonstrated a good understanding about the needs of service users in their care. Observations at the time of this inspection indicated staff were providing positive interactions and that the service users were comfortable with those who were supporting them. An examination three staff records indicated one member of staff had completed NVQ Level 2 and when interviewing her stated she was undertaking her Level 3. Another member of staff had completed NVQ 3. There is a small core group of staff that work in the home and a rota provided by the manager indicated that she is part of the staff team along with her partner. There is always staff available throughout the day. There is one member of staff who is responsible for providing structured activities in the home. The manager and her partner who live on the premises provide Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 20 nighttime support. An examination of two staff recruitment records indicated appropriate documentation was in place including a job application form, two references, contracts, and copies of CRB disclosures, proof of identity including a photograph. The staff recruitment records would benefit in being maintained in files that are structured to allow a clearer means of auditing their contents for future inspections. Staff have completed mandatory training topics including Health and safety, manual handling, food hygiene, fire awareness, first aid, and care of medicines training provided by Boots Pharmacy. Evidence was seen of certificates confirming they had completed these courses, but it was noted they did not have an individual training record and the manager must ensure a training plan or matrix as it is known is developed so that any gaps in training needs have been addressed. Further examination of staff records indicated that the manager was providing appropriate frequency of supervision every two months and records day to day discussions with staff. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 21 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 Service users receive a service form a manager who is committed to improving their quality of life. There is relaxed and friendly that benefits the service users and staff. Service users and staff have the opportunity to comment on the care and support they receive. The service has a range of policies and procedures but a review must be undertaken in ensuring they reflect current practice. Service users interests would be better protected through the appropriate filing of their records. Service users’ health and safety is promoted and maintained with some improvements required. EVIDENCE: The Registered Manager was able to provide a good understanding around the needs of the service users. It was apparent during this inspection the manager cares a great deal for the service users and they appreciate the care and support they receive. She is qualified to the Registered Managers Award and is committed to improving practice. Comments made during the inspection were received positively. The atmosphere was relaxed and friendly and the service users were seen to be able to approach the manager at anytime. One service user said she would go to the manager if she had any worries or concerns. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 22 Staff spoken with stated they would be able to approach the manager and admired her commitment to the needs of the service users. There was evidence seen and when speaking to the staff that they have monthly meetings. The manager undertakes a quality audit that involves satisfaction surveys that were recently completed by service users and their relatives. The comments seen were positive. One questionnaire had been completed by a Continence Advisor who stated that each service user is part of a family and that the staff were very friendly. The service has a range of policies and procedures, which the manager must ensure these, are reviewed on annual basis ensuring they are relevant to current legislation and practice. Generally the records seen were up to date and held in a locked facility. However, the manager must take action in ensuring some of the service users records and those for staff are filed separately and not together in one folder. Records with regard to health and safety were satisfactory although some improvements were required. The risk assessment for the prevention of fire was in need of review and at the time writing this inspection a new fire risk assessment format had been sent to the Registered Manager. The manager stated that fire safety training was currently being arranged for all staff. There was evidence confirming the fire alarms and emergency lighting was being tested on a weekly basis. An up to date Gas Landlords Safety Certificate was in place following the installation of a new gas boiler. The stair lift had been serviced since the last inspection. The kitchen was clean, tidy and the manager had addressed a requirement form the previous inspection for food to be date labelled prior to freezing. It was noted however, that a daily record was not being maintained for the temperatures of the refrigerators and freezers. It was good to see when examining the accident books that none had occurred since the last inspection. The manager takes her responsibility seriously of informing the CSCI of any events affecting the well being of service users. When touring parts of the premises it was noted that the radiators in the service users bedrooms were uncovered and in one a bed was up against a radiator. The manager must take action in ensuring risk assessments are undertaken and cover the radiators so that there is a reduced risk of scalding. One of the service user’s bedroom windows was found not to open to the required safe restricted distance. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 N/A 3 3 4 N/A 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 N/A 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 N/A LIFESTYLES Standard No Score 11 N/A 12 3 13 3 14 2 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 3 3 3 3 2 2 2 N/A Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 24 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 YA1 Regulation 4(1) Sch 1 Requirement Timescale for action 25/03/06 2. YA5 5(1)(a,b)(2) 3. YA6 15(1)(2) The Registered Person must ensure the Statement of Purpose/ Service User Guide is amended to include the following: The sizes of the rooms Where the home does not meet the environmental standards. Whether or not is nursing care is to be provided. The Registered Person must 25/03/06 ensure the statement of terms and conditions makes reference confirming that a holiday will be provided. There must also be a standard form of contact with information of fees to be paid. The Registered Person must 25/04/06 ensure that service users care plans provide further details as to how the needs of service users are to be met, their typical daily routine including their likes and dislikes. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 25 4. YA14 12(2) The Registered Person must ensure the daily recording of service users provide more detail as to how they spent their leisure time during the day and evening. 25/03/06 5. YA18 13(5) 6. YA19 7. YA20 The Registered Person must 24/03/06 ensure staff maintain appropriate manual handling techniques when supporting service users. The manual handling assessments need additional information as support required when bathing and action to be taken in the event of a fall. 12(1)(a,b)(2) The Registered Person must 24/03/06 ensure it develops individual health action plans for the service users living in the home in line with the Department of Health’s Valuing People Guidelines. The record for service users quality audit health checks must state the outcome of any contact with healthcare professionals. 13(2) The Registered Person must 25/03/06 ensure that medication with different names, dosage and strength is written on separate entries on the MAR sheets. Photocopies of prescriptions must be attached to the back of MAR sheets. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 26 8. YA22 22(1) The Registered Person must ensure the complaints procedure is amended to state the CSCI can be contacted at anytime and that no one will be victimised for making a complaint. 22/04/06 9. YA23 13(6) 10. YA35 18(1)(a) 11. YA40 17(3) 12. YA41 17(2) Sch 2,3,4 13. YA42 13(4) 23(4)(v) The Registered Person must ensure staff undertakes training in adult protection. The adult protection procedure needs amending to state that the CSCI must be notified of any incidents of suspected abuse. It must also refer to the use of the Multi- Agency Guidelines published by Birmingham Social Care & Health. The Registered Person must ensure it develops a staff training plan/matrix so that any shortfalls in specific training needs have been addressed. The Registered Person must ensure the policies and procedures are reviewed in ensuring these reflect the National Minimum Standards and any changes in legislation. The Registered Person must ensure that records with regard to service users and staff are stored separately and must not be in the same folder. The Registered Person must ensure the fire risk assessment is reviewed. 25/04/06 25/04/06 25/04/06 25/04/06 25/03/06 Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 Page 27 14. YA42 13(3)(4) 15. YA42 13(4) 16. YA42 13(4) The Registered Person must ensure a daily record is maintained for the temperatures of the freezers and refrigerators. The Registered Person must ensure that exposed radiators in service users bedrooms are covered as part of a risk assessment of the premises to reduce risk of scalding. The Registered Person must ensure the service user identified has his bedroom window restricted to the required safe distance when opened. 25/03/06 25/04/06 25/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA26 YA8 Good Practice Recommendations It is recommended that the Registered Person ensure two double electrical sockets are fitted in service users bedrooms. It is recommended that the Registered Person ensures the minutes for the service users meetings include more information as to how they made their choices and set out what action will be taken when any requests have been made by service users to do different activities. Hallewell Road, 22 DS0000017074.V275915.R01.S.doc Version 5.1 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.V275915.R01.S.doc Version 5.1 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. 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