Inspection on 06/06/05 for 22 Hallewell Road

This inspection was carried out on 6th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

22 Hallewell Road 29/08/07

22 Hallewell Road 20/11/06

22 Hallewell Road 24/01/06

22 Hallewell Road 22/11/04

22 Hallewell Road 02/06/04

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Polesworth Group 70 Long Street

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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 22 Hallewell Road Edgbaston Birmingham B16 0LR Lead Inspector Joan Franklin Unannounced 6 June 2005 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 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 Stationary 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 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hallewell Road, 22 Address 22 Hallewell Road Edgbaston Birmingham B16 0LR 0121 455 8269 0121 454 5177 martomoi@blueyonder.co.uk Mrs Marcella Marie Higgins Telephone number Fax number Email 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 Care Home 3 Category(ies) of Younger Adults, Learning Disability registration, with number of places Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. 2. One named service user with additional physical disabilities may be resident at the home. 3. One exisiting named person can be accomodated and cared for in this home for reason of mental health needs subject to appropriate review of the home`s suitability. Date of last inspection 22 November 2004 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 pemises 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 WC 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 wetern 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 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the 2005/2006 year. The inspection was unannounced, taking place over four and a half hours. The registered manager was available for most of the inspection. There was a tour of the building and the grounds as well as inspecting the records of a service user. Other management records were inspected. All of the service users talked about living at the home. The views of three members of staff were sought. The management of the home and the actions of those living at the home as well as those attending for day care were observed. What the service does well: What has improved since the last inspection? The home has installed a new boiler to restore necessary warmth for those who live and visit there. A new shower has been installed which has improved the washing arrangements for service users. A supervision programme and recording system has been introduced. This gives staff a formal way of looking at their development to continue to respond to the needs of service users. Staff said that they have meetings with the manager. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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 standard(s) 3, 4 and 5 The home has information available to enable prospective service users to make a choice whether they want to live at the home. EVIDENCE: The home has a Statement Of Purpose which has not changed since previous inspections. This allows prospective service users to know about the range of services offered at this home. The home has a day centre attached to it. This functions well as there is adequate staff to supervise activities; the current service users all get on well together; and the needs of the service users are known before they attend the day centre. There remains an intention to ensure that any future service users would only be offered a place following a phased introduction and the involvement of the people who currently live there and who attend the day care. There have not been any new admissions. The manager said that she would not offer a place without discussions with the social worker and talking to everyone living in the home. There is one service user who is aged seventytwo. The manager is of the view that the home offers activities for younger people but does not want the current service user to leave whilst they can meet her needs. Records were inspected that are available to staff to read to know about the situation of each service user. A sample of a contract for a prospective new service user was seen. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 10 Service users confirmed that the systems in place to consult with them are adequate. EVIDENCE: The home pays attention to the changing needs of service users to provide relevant care. One service user’s mobility has deteriorated. He was observed to have further assistance to move around. The home gives service users opportunities to make decisions about what they might be able to do. The ability to do some activities has diminished due to ageing and illness. The home has adapted the care provided whilst attempting to encourage service users to be active rather than not participate. The home attempts to encourage service users to face circumstances which are occurring outside the home though this requires intervention with relatives to provide information so that people living in the home can make decisions about their lives. The home respects issues of confidentiality in that service user are able to take visitors to their own room. Observations and discussions with service users evidenced that they are content with the atmosphere and the routines in the home. A discussion Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 10 between a service user and the manager showed that the views of the service user were being taken into account. The observations of service users having lunch evidenced that staff do respond to suggestions for running the home. There is a policy on confidentiality. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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 standard(s) 14, 15 and 17 The home provides a nutritious diet that contributes to a health lifestyle. Service users are supported to maintain their relationships with family members. A range of leisure activities are provided to afford service users a meaningful lifestyle. EVIDENCE: The preparation and serving of a meal was observed. Service users talked of how they enjoy their meals. Discussions with one service user said that she is settled in the home and enjoys the activities she does in the day centre and her holiday outings. She also talked about her relationship with her sister who is her appointee and is involved in decision making about her lifestyle. She also talked freely about her boyfriend at the day centre who the manager knows. The manager explained that the holiday arrangements are more restricted than they were as one service user now has difficulty travelling due to deterioration Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 12 in his physical health. In discussion with this service user he said he was happy and he was joining in activities at the day centre in the home. There are photographs in the home of the various activities which have been arranged including parties at Christmas. The service users have entertainment in the garden of the home including barbecuing and playing music at the imitation “saloon” which has been built. Service users continue to attend day centres. Some of the attendance is at the home where there is a day centre facility. There is an emphasis on service users being involved in activities. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 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 standard(s) 19, 20 and 21 There has been continued attention to personal health care to service users enabling them to have the best possible health although records need updating to reflect this. The home has not addressed with service users their wishes in the event of death or serious illness. EVIDENCE: The medication sheet on a service user showed that her personal information had not been brought up-to- date following a visit to the psychiatrist and the times of her medication and prescriptions were not current. It is necessary to make sure that the work is transferred onto the records of the service users for the written information to be up-to-date. The manager and the staff talked about the health needs of the service users in a full and caring way. There have been specific issues with a service user whose mental health is affected by the actions of others. The manager talked of how she has taken on the role of discussing matters to try to prevent upset to the service user. The file had details of responses to these discussions. The file on this service user showed there had been no consultation about her wishes in the event of further illness or her death. This is an extremely difficult task which the manager said she would think about to have some way of responding to this situation. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 14 The manager said that the assistance of the community psychiatric nurse had proved very successful with the service user who had been presenting antisocial behaviour in that this was hardly occurring now that she had a chart to follow to eliminate the incidents. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 22 The systems in place ensure that service users feel their views are listened to and acted upon. EVIDENCE: There is an atmosphere of attempting to avoid complaints by having meetings with service users and daily discussions with staff to deal with matters to try to prevent problems. Complaints would be taken seriously and efforts made to resolve issues to maintain good quality care in the home. The manager said that there had been no complaints received in the home. No complaints have been received by the Commission for Social Care Inspection. Two members of staff said that they would speak to the manager about anything that was causing them concern. They said that they had read the last inspection report and are aware of the CSCI. Service users were not asked directly as to how they would make a complaint. Two service users talked about being happy living at this home. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 24, 25, 26, 27, 28 The service users live in a comfortable, homely environment. Some attention is required to ensure that a safe environment is provided. EVIDENCE: A tour of the home revealed all of the different activities that the service users can do. Some of the passageways are narrow because of items placed there. There must be an assessment of the ability of service users to get passed these narrow parts to access facilities. The newly installed shower had caused the water temperature not to be regulated. This needs regulating to provide a safe temperature. The water in the downstairs toilet was too hot for the touch of a hand and presents a risk of scalding. Discussions with the service users gave information that they are happy with their bedrooms and that they enjoy the facilities the home has to offer. The manager said that soiled washing is not taken through the kitchen but through the conservatory. This must be done there is soiled bedding on occasions to avoid the risk of cross infection. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 17 The home has an interest in animals. There was a constant buzzing noise from the fish tank which could be very annoying. Activities of a personal nature, washing hands before lunch happen in the home in full view of people who are there. This routine did not present any discomfort though it might to future service users. The home provides a variety of surroundings from personalised bedrooms, a relaxing lounge, a homely kitchen, and a garden with the distinctive feature of an imitation western setting. All the facilities are provided to create a homely and stimulating environment. Attention does need to be paid to keeping some areas clutter free so that there is space for people to move easily for health and safety reasons. The home is kept clean and attention in given to the necessity of complying with hygiene standards. The provision of a stair lift shows the home wants to enable service users to remain here. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 A team of staff receive training to enable them to meet the needs of people living in the home. EVIDENCE: There is attention to the training needs of staff. One staff member is waiting to have her NVQ level 2 assessment. Training is being arranged on food hygiene and handling to meet standards to prevent risks of illness to people eating at the home. Staff numbers have been increased since the last inspection. The staff rota did not have names entered for each shift. This is an administrative error rather than the unavailability of staff who provide a good level of care. The staff rota had not been written to include the names of staff on every shift which was a requirement at the last inspection. Discussions with three staff members evidenced that they had clear information about their roles. They talked about their commitment to service users to provide care and safety. They mentioned that they considered that the manager is very approachable. Observations of the interaction between staff and service evidenced that there was a kind and thoughtful approach. Two members of staff were seen to prepare service users for eating their lunch at the table in the kitchen. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 19 A service user returned from the day centre. She was welcomed and asked about her day and provided with refreshments of her choice. This young woman readily joked with the manager and with the inspector. Food was not labelled before being placed in the freezer. Supervision notes were seen. These are all on one sheet and should be separated for each member of staff. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 40 and 42 There is leadership from the manager to promote a good standard of care for service users and the development of staff. There are some issues which require attention to improve the safety of people in the home. Policies and procedures are readily accessible in the office for those who are on duty to refer to ensure that standards are maintained. EVIDENCE: The manager showed records that a fire drill has not taken place for more than six months. The manager said that she intends to arrange this by the end of the month. Records were seen to show that the fire alarms are now tested daily. There is currently a stable staff team. The member of staff who is about to finish her NVQ 2 would like to remain to complete level 3 which the manager is considering. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 21 The manager had obtained CSCI leaflets completed since the last inspection from relatives and a registered nurse who runs the home when the manager is away. This is part of the Quality Assurance system in the home. The completed sheets made positive comments. The manager said that she is continuing to develop this system with another manager of a home which is next door. Food must be labelled with dates when placed in the freezer. The manager’s partner was able to provide records of his involvement in the home. This contributes to the efficient running of the home. A member of staff from the home’s accountants was there auditing the account to ensure financial viability. Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 3 2 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 x Standard No 11 12 13 14 15 16 17 x 2 x 3 3 2 3 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hallewell Road, 22 Score x 2 2 2 Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 2 x E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 23 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 24 Regulation 4 (b) Requirement The manager must apply to the CSCI for a variation now that there are service users aged over 65 Locks must be orovided on bathroom doors The medical records for service users must state the precise time of administering the medicine and have details of all the current medication ensuring that previous medicines are removed from the sheet on medicines Make arrangements to include details on the service users plan of the older service users their plans in the event of illness or death. This may depend on involving a relative. The constant buzzing of the fish tank must be repaired to stop the noise Contact the Gas Board who installed the shower to return the water to the regulated temperature of 43 Arrange a fire drill for eveyone Label food before placing in the freezer Timescale for action within 3 months 31-07-05 immediatel y 2. 3. 27 20 12 (4) 13 (2) 4. 21 15 2 (b) 14-072005 5. 6. 24 42 23 2 (c) 23 2 (j) Immediate y Immediatel y 30-062005 immediatel y Page 24 7. 8. 42 42.2 (iv) 23 4 (e) 16 2 (g) Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 9. 10. 15 24 18 3 (4) Records of the health needs of service users must be kept up-to -date Remove clutter from hallways to reduce the risk of accidents for service users to go into the garden 30-06-05 30-06-05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Hallewell Road, 22 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Birmingham and Solihull Local 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 E54 S17074 Hallewell Road 22 V230873 060605 Stage 4.doc Version 1.30 Page 26 - 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. 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