Inspection on 09/02/06 for 35 Hawthorn Road

This inspection was carried out on 9th February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 Hawthorn Road 17/08/06

35 Hawthorn Road 12/10/05

35 Hawthorn Road 21/03/05

35 Hawthorn Road 04/08/04

35 Hawthorn Road 23/01/04

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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 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorn Road, 35 Erdington Birmingham B44 8QS Lead Inspector Kerry Coulter Unannounced Inspection 9th February 2006 12:10 Hawthorn Road, 35 DS0000030424.V282538.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 Hawthorn Road, 35 DS0000030424.V282538.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. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawthorn Road, 35 Address Erdington Birmingham B44 8QS 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) 0121 384 2228 Sense West Paul McDonald Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Minimum of 3 suitably qualified staff on duty, as well as the care manager, from 7.30am - 10.00pm An additional member of care staff provided for six hours across the day All residents must be under 65 years of age That the registered manager undertakes a minimum of 21 hours dedicated management/administration time a week. That the registered manager completes NVQ 4 in Care by July 2006. Date of last inspection 12th October 2005 Brief Description of the Service: Hawthorn Road is a care home owned by Sense, who provides services to people who are deaf, blind and have associated disabilities. Hawthorn Road was first registered in December 2002, it is a traditional house, which was purpose designed to meet the needs of people with visual and hearing impairments and associated learning and communication difficulties. Hawthorn Road is currently home to five people with an age range from early thirties to early fifties. On the ground floor there is a communal lounge, a quiet sitting room and a dining room. There is a staff office, toilet and a laundry. One of the bedrooms is on the ground floor. On the first floor there is a further four bedrooms all with ensuite facilities. The home does not have a lift, so only ground floor accommodation is accessible to someone with mobility needs. To the rear of the house there is a large garden with mainly grassed area and a patio. The garden also has a brick built sun house, which has the potential to be used as additional space for service users. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in one afternoon by one Inspector. The Manager and the staff on duty were spoken to. Service users were unable to give a view of the home due to their communication needs. A partial tour of the premises took place. Care, staff and health and safety records were looked at. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from October 2005. What the service does well: What has improved since the last inspection? Risk assessments have been further developed to include good detail to show clearly that they have been reviewed. A Manager has been registered for the home that can lead the staff and support them to meet the needs of service users. Complaints formats have been developed so that they are now available to include the Widget system on CD Rom and an audio CD. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 6 There is a brick sun house in the garden. A heater has now been purchased for this room so that it can be used by relatives to meet with service users in private if they wish to do so. A new assisted bath has been installed, in line with recommendations from the Occupational Therapist. Discussions with staff indicate that this service user is now really enjoying being able to have a bath. 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. Hawthorn Road, 35 DS0000030424.V282538.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 Hawthorn Road, 35 DS0000030424.V282538.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): N/A These standards were not assessed. Standard 1 and 2 were met at the inspection in October 2005. EVIDENCE: Hawthorn Road, 35 DS0000030424.V282538.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): 9, 10 Strategies for managing risks were clearly identified and ensures that appropriate guidance is available to staff to enable them meet individual needs. EVIDENCE: Service user risk assessments were sampled. Risk assessments included all the activities that service users are involved in as well as the risk to the individual if there was a fire and the risks of their health needs such as epilepsy. The risk assessments had been recently reviewed as required at the last inspection. There was evidence that the staff team sign to state that they agree with the assessments. It is good practice that in addition to reviewing assessments six monthly some regarding challenging behaviour had been reviewed more frequently following a critical incident occurring. Work has also begun to highlight the level of risk. Discussion with the Manager indicates that this is to be further developed as Sense is in the process of revising the risk assessment format. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 10 Service users individual records are stored securely. Staff are mindful of issues discussed in the presence of service users, and were not observed to breach confidentiality. Care plans were not sampled, they were found to meet the standard at the inspection in October 2005. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13 Arrangements are in place to ensure that service users experience a meaningful lifestyle. EVIDENCE: Sampled records, discussion with staff and observation of practice show that service users are encouraged to be as independent as possible, with opportunities available for personal development. Service users are encouraged to get involved in domestic activities, communication is facilitated by various means to include body language and objects of reference. It was positive that discussions with one member of staff indicate that the staff team focus on what the service user can do for themselves, rather than what they can’t. A varied and fulfilling range of activities are offered, to include use of community facilities. Each service user has an individual activity time table. Activities on offer include the cinema, cooking, rock climbing, ice skating, music, horse riding and massage. One service user makes regular use of the local library for the loan of audio books. On the day of the inspection service users were involved in out of house activities to include shopping and horse Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 12 riding. Discussion with staff indicates that new activities are under consideration for some service users. One recently introduced activity has been aerobics, staff said that service users were really enjoying this. A large party was organised for the 50th birthday of one service user. A large social club and DJ was hired, lots of people attended. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The systems for the administration of medication are generally good and only minor improvement is needed to fully meet the required standard. EVIDENCE: Generally administration of the medication appeared to be good. Medications had been signed when administered and as received. Boots supply the medication to the home using the monitored dosage system. FP10 prescriptions had been copied and retained. It is good practice that competence assessments are completed for staff administering medication. Topical creams and ointments had been dated on opening. No Controlled Drug’s (CD’s) were prescribed for service users. One service user was prescribed Gaviscon liquid for indigestion on an ‘as required’ basis. The administration guidelines said that either 5mls or 10mls is to be given. A written protocol needs to be available to guide staff when to administer the medication and when 5 or 10mls should be given. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a satisfactory complaints procedure available in a variety of alternative formats. Some physical intervention recording is lacking and may impact on the homes ability to ensure that service users are being protected from abuse and that their welfare is being promoted. EVIDENCE: The organisation, Sense, has produced a policy, referred to as ‘issues policy ’in respect of complaints. This was assessed as meeting the required standard at the inspection in March 2005. The Manager said that no complaints had been since the last inspection. All of the service users at Hawthorn Road are very dependant on staff interpreting/facilitating any concerns /complaints that they may have. At the last inspection the Inspector was informed that the home was in the process of producing the complaint procedure in alternative formats to the written version that are more suitable/accessible for service users. This has now been done with formats available to include the Widget system on CD Rom and an audio CD. The home/organisation has a detailed Adult Protection policy and the Birmingham Multi Agency guidelines were also available. It was identified at the inspection in October 2005 that staff at the home have received training in adult protection. Sometimes there are agency staff on duty. Profiles from the supplying agency were available to show that the staff had Criminal Record Bureau checks completed, to ensure service users are not put at risk by unsuitable people working in the home. Sometimes the use of physical intervention has been necessary with service users to protect them, and others from harm. It was identified at the last inspection that not all incidents had been notified to the CSCI as required. This Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 15 is now being done. It was also previously identified that records on the use of physical intervention required improvement to include the length of the intervention. At this inspection five completed records were sampled, four did not record the duration of the intervention. It is essential that this is recorded to ensure the staff show that the duration of the intervention was for no longer than necessary. An incident occurred in the home that was recognised by the Manager as having possible adult protection implications. CSCI and the service users social worker were appropriately notified of the incident. This is currently under investigation by the Manager. On completion the CSCI and Social Worker must be made aware of the outcome. The financial records for one service user were sampled. These were found to be satisfactory with receipts available for expenditure. It is good practice that financial audits are undertaken by Sense, the last one was completed in February 2005. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 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 the following standard(s): 24, 28, 29, 30 Service users live in a clean, homely, comfortable and safe environment that generally meets their individual needs. EVIDENCE: 35 Hawthorn Road is a traditional built house that has been adapted to meet the needs of service users. All service users have single bedrooms with ensuite. The home has a range of communal space for service users use, including a good-sized domestic style kitchen, separate dining room and two lounges. However one of the lounges is used mainly by one service user who likes their own space. Where decoration of worn areas is required and worn furniture requires replacement action has already been taken to address this. New seating is on order for the lounge, this is due to arrive in March. The decorators were also due at the home the week following this inspection to repaint hallways, the dining room and a service user bedroom. To the rear of the home there is a very large garden with a patio area and a large grass area with a covered pond. There is a brick sun house in the garden. A heater has now been purchased for this room so that it can be used by relatives to meet with service users in private if they wish to do so. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 17 Around the home there are tactile indicators to indicate to service users where doors, stairs and other hazards are. The lounges, dining areas and kitchens also have tactile indicators. Systems are also in place to alert the service users to someone entering the room, for example via a fan switching on. Since the last inspection one service user has had a new assisted bath installed, in line with recommendations from the Occupational Therapist. Discussions with staff indicate that this service user is now really enjoying being able to have a bath. The home was found to be clean, hygienic and free from offensive odours at the time of the inspection. Liquid soap and paper towels were available for hand washing. The laundry is accessed off the main hallway and there is direct access to the garden where there is a rotary washing line. The home has a sluice cycle washing machine. Food stored in the fridge was date labelled to reduce the risk of service users from getting food poisoning. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 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 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 The staffing arrangements ensure service users are supported by sufficient numbers of knowledgeable staff to meet their needs. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company; staff give support with warmth, friendliness and patience and treat people respectfully. Two members of staff spoken with had a good understanding of the needs of the service users they work with. Both were aware of the recent changes to the behaviour management guidelines for one individual. Discussion with the Manager indicates that a large proportion of the staff team are relatively new to the home. Therefore only three of the fifteen staff have completed an NVQ in care. However several staff are enrolled on NVQ and so this figure should rise in the future to meet the standard of 50 of staff having an NVQ. On discussing training with staff members it is evident that the organisation is committed to training. NVQ clinics are available to staff on a monthly basis. Staffing levels are a condition of registration and the home was found to be meeting these conditions of registration. The home has three full time vacancies, with two of these having been recruited to. Rotas show some use of agency staff but this has not been excessive with regular agency staff being Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 19 used. Since the last inspection a new Practice Development Worker has commenced work in the home with responsibilities to include care plan development. Records show that staff meetings are held on a monthly basis, giving staff the opportunity to discuss issues important to the smooth running of the home, for the benefit of service users. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 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 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): 38, 42 The service users benefit from the management style at the home. Systems are in place to promote the health and safety of service users. EVIDENCE: Since the last inspection the Manager has been successful in his application to be registered with the CSCI. Members of staff stated they felt they could approach the Manager with any concerns, one said that he had been very helpful in providing training and support to undertake their new role. Service users and staff generally have their health and safety promoted by the procedures in the home. Regular health and safety audits are completed. Records evidenced the regular testing and servicing of fire alarms. Staff have received recent fire training, where this is required for one staff evidence was available that they were booked on to forthcoming course. Equipment in the home is regularly serviced. Up to date detailed risk assessments for the premises, risk of fire, staff and food had been completed. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 21 The fridge and freezer temperatures are taken daily and these were within safe food storage limits. Staff test the water temperatures regularly and records showed that these are maintained at a safe temperature. A certificate was available to evidence that gas appliances were safe, and certificates showed portable electrical appliances had been inspected and were safe to use. Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 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 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X 3 X X X 3 X Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes (one) STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Ensure that a written protocol is available to guide staff regarding the administration of Gaviscon medication on an ‘as required’ basis. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Outstanding from 30/11/05. Timescale for action 17/02/06 2. YA23 12(1) 13(6) 07/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn Road, 35 DS0000030424.V282538.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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