CARE HOME ADULTS 18-65
Hamstead Hall Road, 43 Handsworth Wood Birmingham West Midlands B20 1HT Lead Inspector
Gerard Hammond Unannounced Inspection 24th March 2006 10:35 Hamstead Hall Road, 43 DS0000016929.V287562.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 Hamstead Hall Road, 43 DS0000016929.V287562.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. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hamstead Hall Road, 43 Address Handsworth Wood Birmingham West Midlands B20 1HT 0121 523 5472 0121 523 5472 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) londonroad@tiscali.co.uk Milbury Care Services Limited Ms Veronica Christopher-Fellows Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may provide care for four (4) service users with a learning disability aged under 65 years. 5th January 2006 Date of last inspection Brief Description of the Service: 43 Hamstead Hall Road is registered to provide accommodation, care and support for four people who have learning disabilities. The Home is run by Milbury Care Services, and the current resident group of four men have been together for a number of years. The house is a domestic scale detached property, located in a quiet, wellestablished residential neighbourhood in the Handsworth Wood area of Birmingham. There are good public transport links for this locality. Downstairs there is a comfortable lounge to the front of the house. There is a separate dining room at the back of the house, and this gives access to the garden through patio doors. There is also a kitchen, separate laundry and toilet on this floor. All of the bedrooms are situated on the first floor, accessed by the staircase leading from the front hallway. There are two single rooms and one double, currently shared by two brothers. A small box room serves as an office. The domestic scale bathroom includes toilet facilities. There is a paved driveway at the front of the house offering limited parking. To the rear of the property is a private enclosed garden. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection visit of the current year, and was unannounced. This report should be read in conjunction with the one written following the inspection completed on 26 October 2005. Direct observation and sampling of records (including personal files, care plans, previous inspection reports and safety records) were used for the purposes of compiling this report. The Inspector met all of the residents. People’s learning disabilities and their communication support needs meant that it was not possible to seek their views directly. The Registered Manager was interviewed formally, and a tour of the building was completed. What the service does well: What has improved since the last inspection?
The Manager continues in her efforts to meet Standards and to address requirements made at the time of the last inspection. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 6 Significant work has been done to develop care plans and to begin seeking to set goals appropriately. Risk assessments are now cross-referenced with care plans to support better information management. Requirements regarding medication management have been met, so that blister packed PRN (“as required”) medicines are returned to the pharmacy at the recommended times, and the medication fridge is defrosted regularly. The staff training and development plan has been brought up to date. Requirements regarding fire safety checks and the maintenance of appropriate records have now been met. 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. Hamstead Hall Road, 43 DS0000016929.V287562.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 Hamstead Hall Road, 43 DS0000016929.V287562.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): EVIDENCE: Key Standard 2 and Standard 3 were assessed at the last inspection, and met in full. There have been no admissions to the home since that date. The current group of four men living in the house have been together for several years. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Care plans are being developed as required, but further work needs to be done to ensure that the outcomes of goals set can be measured. Residents are supported to take risks in a responsible manner and risk assessments continue to be developed. EVIDENCE: Key Standards 6, 7 and 9 were assessed at the last inspection. Standard 7 was fully met, and Standards 6 and 9 partially met. A requirement was made that individual care plans should be developed to include goals with outcomes that can be measured. Sampling of care plans revealed that some good work has gone on in this regard, and this should be acknowledged. Where plans have been reviewed since the last inspection, clear efforts have been made to set goals. Some of these are quite specific (e.g. supporting resident to maintain a healthy weight by monitoring weight on a weekly basis) but there is further room for development. For example, his care plan in this area could also have some specific targets such as “ensure that J has the recommended five portions of fruit and vegetables at least five times each week” rather than just support him to have a healthy diet.
Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 10 A further requirement was made that risk assessments should be crossreferenced with the care plan(s) to which they relate, and vice versa: sampled plans showed that this had been done. The requirement that control measures are appropriately included in care plans was not fully assessed on this occasion. Records of individuals’ reviews now include a place for setting short, medium and long-term goals. Where goals are set, there should be clear links to assessed needs and plans of care. Future reviews should show how goals have been evaluated. It is suggested that the inclusion of a direct question such as “how will this goal be measured” into the care plan format might prompt staff to consider this aspect specifically. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 12,13, 15, 16 and 17 were all assessed at the last inspection and met in full. In the course of sampling resident’s personal files, it was noted in particular that activity recording is somewhat limited, and this is an area that requires some attention. Activity recording should provide some indication as to the purpose of activities undertaken. There should be clear links to individuals’ assessed need, plans of care and agreed goals. The activity opportunities available to people are a prime indicator of the quality of life they enjoy. It is important that full and accurate information is available so as to inform appropriately review and future care planning. This will be assessed more fully at the next inspection. One man living at Hamstead Hall Road has sensory impairment. Some time ago, he was assessed as requiring specialist support to meet his sensory and personal development needs, and it was suggested that he would benefit from attending a day centre specialising in this area. The Registered Provider should pursue this matter with the commissioning authority, to ensure that this man’s care needs are met appropriately.
Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 12 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, 20 Residents receive personal support in accordance with their needs and preferences. General practice and procedures in handling and administration of medication is good, but all staff must take personal responsibility to ensure that procedures are followed correctly. EVIDENCE: Key Standards 18, 19 and 20 were assessed at the last inspection. Standards 18 and 19 were fully met on that occasion, and Standard 20 partially met. Direct observation of resident’s personal grooming and attire continues to provide evidence that they receive a good standard of basic personal care. As previously noted, interactions were warm and friendly, and support offered respectfully and considerately. Previous requirements with regard to the handling, storage and administration of medication in the home have now been met. Blister packs of PRN (“as required”) medication are only retained for the appropriate eight-week period. The schedule for defrosting the medication fridge has now been amended to indicate the next date on which this should be done.
Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 13 Since the last inspection, the Manager has reported two separate incidents of serious concern regarding handling and administration of medicines. The Medication Administration Record (MAR) was examined and was appropriately completed, apart from the matters mentioned above. The Manager has reviewed procedures and investigated the incidents reported appropriately. All staff who handle or administer medication must take personal responsibility for carrying out their duties as required, and for maintaining complete and accurate records. Appropriate procedures are in place, but these must be implemented effectively. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 22 & 23 were assessed and fully met at the time of the last inspection visit. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 28 Resident’s rooms suit their needs and communal spaces complement these satisfactorily, but some items remain in need of attention. EVIDENCE: Key Standards 24 and 30 and Standards 25, 26, 28 and 29 were assessed at the last inspection. All Standards assessed were met in full, with the exception of number 25, which was partially met. The window in resident J’s bedroom is still in need of replacement. A number of other items in shared areas of the house are in need of attention, and these are detailed in the requirements section of this report. In particular it was noted that the downstairs shower room has no source of heat and on the day of the inspection visit it was distinctly cold. The sliding door to this room does not operate effectively. Consideration should be given to developing the garden space for the benefit of all the residents, but in particular for the person with sensory impairment. Advice should be sought about how to do this effectively. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 16 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): 34 Recruitment policy, procedure and practice promote resident’s protection and safety. EVIDENCE: Key Standards 32 and 35, and Standards 33 and 36 were assessed at the last inspection. Standard 35 was partially met and a requirement made that a current staff training and development plan was submitted to CSCI. This was provided as requested. Shortfalls in training to support people with epilepsy, and adult protection training need to be addressed. The remaining Standards were met in full. Staff records were sample checked and it was noted that necessary documentation was held appropriately. Recruitment is dealt with centrally and appropriately robust procedures are in place. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 17 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): 39, 42 Reports of quality assurance and monitoring activity should be developed to demonstrate clearly how resident’s views underpin review and development of the service. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: Key Standards 37 and 42, and Standards 38 and 41 were all assessed at the time of the last inspection, and fully met. It was noted that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) have not met the required standard over the past twelve months. The Registered Provider must ensure that this is done at least every month, and that visits are unannounced. It should be acknowledged, however, that the current Operations Manager has only recently come into post and that visits and reporting have been carried out as required within that time.
Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 18 A copy of the home’s annual audit was seen. The Registered Provider should consider how this might be developed to indicate clearly how resident’s views have underpinned the review and development of the service. Safety records were sample checked. The fire alarm and fire-fighting equipment have been serviced. The fire alarm has been tested and a written record maintained as required. A fire evacuation drill has been completed recently and the record indicates the names of all those who took part, as appropriate. Records of temperature testing of water, fridge and freezer, and cooked food were examined, and completed as necessary. A current certificate of portable appliance testing was forwarded following the inspection visit. Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 19 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 2 26 X 27 X 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X X X 2 X X 3 X Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 20 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 YA6 Regulation 15 Requirement Individual care plans should be developed to include goals with measurable outcomes. These should be evaluated at review, and amended or reset as required. (Partially met) Ensure that control measures from risk assessments are included in individual care plans. (Not assessed on this occasion) Pursue specialist support to meet the individual care and development needs of the resident with sensory impairment. Develop activity recording to include sufficient detail to indicate the purpose of activities undertaken and demonstrate clear links to individuals’ assessed needs, care plans and agreed goals. Replace the window in the rear single bedroom (Outstanding since 31/01/06) Fit light shade appropriate to this resident’s needs and redecorate the bedroom. Replace light shade in upstairs
DS0000016929.V287562.R01.S.doc Timescale for action 30/06/06 2. YA9 13 (4) 30/06/06 3. YA11 16 (2m-n) 30/06/06 4. YA12YA13 16 (2m-n) 30/06/06 5. YA25 23 (2b) 30/06/06 6. YA27 23 (2) 30/06/06
Page 21 Hamstead Hall Road, 43 Version 5.1 7. YA28 23 (2) 8. YA39 24 26 bathroom. Secure toilet seats in upstairs bathroom and downstairs w.c. Repair sliding door to downstairs shower room, and install heating in this room. Redecorate, repair or replace external windows. Replace light shade on upstairs landing. Redecorate laundry room. Replace carpet in upstairs office. Develop garden space, with particular reference to meeting the needs of resident with sensory impairment. Develop reporting of quality assurance and monitoring activity to reflect how the views of residents have been taken into account. The Registered Provider must ensure that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are completed each month. 30/06/06 30/06/06 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. Refer to Standard YA6 Good Practice Recommendations Remove material from personal files that is not current, and dispose of it or archive as appropriate. Build on the excellent work already done to develop clear communication guidelines for each resident, and place these prominently on individual care plans. Mark the counterfoil stubs in the Accident Book with the initials of the person concerned and the date of the report. (Not assessed) 2. YA19 Hamstead Hall Road, 43 DS0000016929.V287562.R01.S.doc Version 5.1 Page 22 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
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