Inspection on 25/05/06 for 228 Kingsbury Road

This inspection was carried out on 25th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 44 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

228 Kingsbury Road 06/02/07

228 Kingsbury Road 31/01/06

228 Kingsbury Road 20/09/05

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 09/07/2008.

CARE HOME ADULTS 18-65 Kingsbury Road, 228 Erdington Birmingham B24 8QY Lead Inspector Alison Ridge Unannounced Inspection 25th May 2006 08:20 Kingsbury Road, 228 DS0000065003.V293609.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 Kingsbury Road, 228 DS0000065003.V293609.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. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kingsbury Road, 228 Address Erdington Birmingham B24 8QY 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 382 5493 Caretech Community Services Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: 228 Kingsbury Road is an adapted domestic property. The home offers accommodation over three floors, and comprises of a lounge, relaxation room, kitchen/diner, ground floor wc. On the first floor are three single bedrooms, and a bathroom. On the second floor is a staff sleep in room/office. The home has a rear garden, and a laundry is located in out buildings. Service users require full mobility to live in this home. The service provides care and support to three adults who have a learning disability, and some behaviour that challenges. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was undertaken over one day, starting early in the morning, so as to meet with the people who live in the home, prior to them leaving for day opportunities. Information used in this report was collected by talking with the residents of the home, observing the care and support they received, tracking care through records, looking at the home, and reading about staffing, and health and safety from records. The manager returned a CSCI questionnaire about the home, and three comments cards from residents prior to the inspection. A new manager has started work at 228 Kingsbury Road. She was present for the whole inspection. This is a home the CSCI has been concerned about. This visit did not show that the shortfalls previously identified had been sorted out. It was of concern that only eight of the previously made requirements were assessed as being met, and that in addition to those carried forward further requirements were made. This home will be subject to additional visits to ensure that the requirements made, are met, and that the health and welfare of the three people living at the home is being protected. What the service does well: What has improved since the last inspection? Caretech, who owns this home, have arranged for the lounge, hallway, kitchen and dining room to be repainted. A new sofa, comfy chair and carpet had been provided in the lounge. This has made the home look much nicer and brighter in these areas. A manager has been recruited for the home. During the inspection this person appeared motivated, and able to tackle the shortfalls in the service that were identified. At the last visit, problems were identified with heating and hot water. A new boiler has been fitted, and this problem has now been resolved. The home was warm, and there was hot water at the time of the inspection. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 6 Staff had generally got better at planning transport, and using public transport with the residents. This has resulted in residents having more money to spend on personal items such as clothes, and toiletries. Medication management was generally good. Some minor shortfalls were noted. These are mainly good practice matters, and the inspector believed the right medication was being given at the right time. The staff had been supported by a senior member of staff, in a recorded supervision. It was positive that in the files sampled, these had all been undertaken recently. What they could do better: The inspection identified that the running of this home needs to get better in nearly all of the areas assessed. Caretech has addressed this by employing a new manager, and changing the service manager’s support arrangements at this home. The people living at 228 Kingsbury Road have some complex needs in addition to requiring help and support with daily life. These needs had not been well planned for. The inspector was particularly concerned that needs around challenging behaviour, and access to the community had not been addressed. Records showed some occasions where one resident had hurt another person. It was not evident these risks had been assessed or planned for, or that adequate action to ensure the possibility of this happening again had been taken. It was positive that staff undertake “talk time” with the people living in the home. It was disappointing to find that the ideas raised during these meetings were rarely followed through. People had said they would like to go swimming, or to the cinema for example, but records of activities offered and undertaken did not show these had been provided. The talk time needs to be developed to include people’s opinions about their care, and how they would like it to be planned and delivered. Some new work had commenced on assessing risks people face, and pose. The work undertaken was to a good standard, but was only for one of the three people living in the home. The opportunity for people to undertake learning opportunities, such as going to a day centre or college were good. The opportunities for people to undertake community-based leisure were poor. Records showed that even on people’s “day off” from college they were offered access to the community, and in all the weekends sampled all activities were in house, and consisted of housework, music, TV and board games. The staff on duty did not support people to undertake personal care after breakfast and before leaving the home. The inspector observed people laving Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 7 the home with food on their face, hands and clothes. One person left the home with a very runny nose. The records did not show that people had been offered appointments with the optician or dentist recently. Monitoring records about menstruation had not been completed since February. In one file two weight records were available for the same period of time. These showed differences in weight of up to 8 lbs for the same month. Specific needs such as autism, mental ill health and difficult to manage behaviour were not planned for adequately. Records about incidents were found located throughout the care file, the inspector could not establish a clear baseline of how many incidents had occurred. The provider-Caretech had undertaken work on the premises since the last inspection. The work undertaken was nice, but the remaining areas of the home look very worn. Two of the three residents bedrooms were in need of redecorating, and all bedroom’s required new furniture, and for carpets to be cleaned or replaced. The bathroom suite appears in good order, but the décor and smell in the bathroom requires attention. The dining room table appeared very worn, and was dirty. The manager reported a request for these items has been made to Caretech. The home required a good clean in all areas. The bedrooms were dusty, and in need of hovering. Spills were evident on walls around the home that had not been wiped up. The ground floor wc, smelt bad, and was very dirty. The recruitment records of four staff were assessed. The files didn’t all have the required information to show that the right checks had been made before staff started work. 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. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X Not assessed at this inspection. EVIDENCE: This home has a very stable service user group, and there had been no new admissions. These standards were not assessed. Kingsbury Road, 228 DS0000065003.V293609.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, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Service users did not have a plan of care that underpinned their known needs, or assessed risks they pose or are exposed to. It was not evident service users are involved in the planning or review of their care. EVIDENCE: Each service user does have an individual plan of care. These have been assessed as requiring significant development to fully reflect the care and support needs, and the wishes of each service user. Some positive work had been undertaken on the Individual support plan. Examples of how this needed to be further developed to clearly state how the support is to be provided, or to signpost the reader to supporting documents was identified. The care notes were found to contain some contradictions, such as in one place a service user being described as having good verbal communication, and good clear speech, and in another document in the same file it was recorded the person was being assessed by the Speech and Language therapist, regards Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 11 difficulties communicating which were leading to frustration, and some difficult to manage behaviour. A communication plan was not available in the files sampled. Entries in the plans such as, ”I have used Makaton symbols in the past, and will sometimes use them to communicate does not provide staff with clear information on how to converse with the service user. It was of concern that a communication aid/day planning tool had been given to one service user by a Speech and Language therapist. It was not in use, noted in the plan of care or available in the home. Staff had undertaken talk time with service users on a regular basis. This was largely focussed around planning activities. It was unacceptable to find that the information and ideas raised by service users during these meetings, had not been actioned, or plans put in place to help service users work towards the goals. It was positive that the acting manager has developed some quality questionnaires that she intends to use with service users, that explore there broader experiences of the service. Service users pose risks, and undertake activities, which present risks. Assessment and planning for these risks was generally poor. Some work to further develop risk assessments in one service users file was evident. These were generally to a good standard. The inspector was concerned that some risk assessments had missed the risk being assessed, and an example of using public transport was shared. The risk assessment focussed on the risk of the public misunderstanding support interventions as abusive, rather than the risks to the service user, staff and public in undertaking this activity. No strategies to support the service user develop new or appropriate skills to deal with the activity were in place, which would have been an obvious control measure. At the previous inspection incidents were noted where one service user had harmed another person living in the home. Further incidents were identified at this inspection, and no risk assessment or strategy to ensure the safety of the service users was in place. The risk assessments were graded as “High”, “Medium” and “Low” risk. The assessments available did not state how this was calculated, and the inspector concluded it was very much down to the opinion of the person writing the assessment. The records regards service users care, were securely stored. No breaches of recorded information were observed. Kingsbury Road, 228 DS0000065003.V293609.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Service users do not have opportunity to undertake leisure activities of their choice on a regular basis. Records did not evidence what food service users had actually eaten, or that this was in line with their needs or preferences. EVIDENCE: The three service users all have opportunity for personal development at day placements. These include college courses, and a day centre. It was positive to see some new work to help service users develop household skills. The inspector also identified the need to include development in support plans, and examples of writing plans which aid service users develop greater independence in bathing, dressing, or personal care were shared. The opportunity to undertake activities was tracked for two service users over the month of May 2006, to date. With the exception of planned day opportunities and two trips to a Gateway club, no community activities had Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 13 been undertaken. In the most recent talk time service users had identified they would like to go swimming, the cinema, visit family, have a pub lunch, and local walk. None of these activities were recorded as being offered or undertaken. The record of in house activities did not show that these were interesting or varied. The most frequent activities were watching TV, listening to music, playing board games and undertaking household chores. No community activities had been undertaken at the weekend. The inspector concluded opportunities in this area, are unacceptably poor. Service users are supported to stay in touch with their family. Comparison of the daily notes, and talk time records did not evidence this was with the frequency requested by the service user. No comment cards were received from family members, and none visited the home during the inspection. The food planned on the menu was interesting, nutritious and varied. There was a stock of fresh products available. Service users were observed to choose their own packed lunch, and to talk about the evening meal. It was identified that staff do not record the food eaten, and during the inspection the food consumed was different to that planned on the menu. It is required an accurate record of food eaten be maintained. The reason why service users have melamine plates and cups was raised. No risk assessment or restriction regards this area was available, and it is required service users be supported to utilise crockery, unless risk assessment dictates otherwise. Kingsbury Road, 228 DS0000065003.V293609.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Service users personal care was not planned or undertaken to an acceptable standard. Service users healthcare needs had not been well planned for, monitored or addressed. Medication was being given as prescribed. EVIDENCE: The service users were supported by staff to undertake personal care in the morning. The inspector did raise concern that no staff prompted service users to clean their hands, face or change their clothes after breakfast, and all three service users left the house with food residue on them or their clothes. One person also left with a running nose. The plans of care have been developed to include some guidance on personal care needs. These need to be further developed to include how this is to be undertaken. The records of healthcare did not show that people had been reviewed by the dentist or optician. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 15 One service user had two weight charts in place. On some months these showed significantly different weights. Records of menstruation had last been recorded on in February 2006. The inspector could not evidence if this was a recording error, or if the service user should be seen for a health review. Some service users have a mental health component to their care needs. These were not planned for. The service users all have some difficult to manage behaviour. No strategy to underpin this was available. No consistent monitoring was being undertaken. Records were found throughout the care file, and it was not evident these had been reviewed, or used as evidence towards service or care planning. One entry recorded an activity had not occurred due to a behaviour issue. It was not possible to establish from the records available what this was, and why it had impacted on the activity for all three service users. Staff had commenced Health Action planning with service users. The documents had been partly completed. During the inspection a Community nurse visited the home. It was positive that her input had been sought. She expressed that her experiences of the home were positive. Medication management was generally good, and with the exception of one product, the inspector could evidence medication was being given as prescribed. It is required that staff ensure only one MAR chart is available for each product. A potential error could occur, where duplicate MAR charts are in operation. One product had not been signed for on three occasions. It was not possible to evidence this product had been given as prescribed. It is recommended that a sample signature list be developed for all staff that administers medication. The storage of medication was in good order. It was noted the storage area was very warm, and it is recommended this be monitored to ensure the temperature does not have a negative effect on the therapeutic value of the medicines stored. It was positive that staff had sought information about the service users wishes, and that of their family in the event of them becoming ill, or passing away. The inspector did raise concern at the insensitive way in which this had been raised with families. Caretech had already taken action to address this. Kingsbury Road, 228 DS0000065003.V293609.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Records of the action taken in response to complaints had not been maintained. Planning of care and procedures for safeguarding service users property identified service users safety and best interests were not being well protected. EVIDENCE: Caretech has a detailed complaints procedure which if followed would ensure concerns are robustly investigated. A complaint had been made since the last inspection. It is required that this be logged in the home, and action taken in response to the concerns be maintained. Caretech has an Adult Protection procedure, which has been amended to include reference to Local Multi Agency Guidelines. The inspector remained concerned that the flowchart makes no reference to ensuring the service users safety, and the policy doesn’t mention this until the second page-point 5. The inspection identified that valuable items, including TV’s had been discarded. It was believed it was after they had been broken. The inspector has required better recording of the rationale for this be undertaken to ensure service users property is protected. The inspection identified occasions where one service user had harmed another. It was not evident this risk had been well assessed or planned for, and that all possible action to prevent people being placed at risk of harm was in place Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 17 It has been required that communication and planning regards transport for service users to and from college be reviewed and improved. During the inspection poor communication resulted in a taxi being ordered for and paid for by a service user, when it would have been possible to undertake the journey on public transport, a much cheaper option. Staff must ensure they represent service users best interest, when spending their money. The balance of one service users money did not tally with receipts and records. It was required this be reviewed, and the money balanced. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Some parts of the home had been subject to redecoration and refurbishment. Further work is required to cleanliness, redecoration and refurbishment to ensure a comfortable, clean and homely environment is provided. EVIDENCE: 228 Kingsbury Road is a domestic building, which feels very much the home of the three service users accommodated. It was pleasing to find that the lounge, hallway and kitchen/diner had been repainted, new lounge furniture provided and new flooring provided in the lounge and kitchen. One bedroom had been re-decorated, and some repairs undertaken. This work just needed to be completed with, “Homely touches”. It was also positive to hear a new boiler had been provided, and the heating and hot water supply had improved subsequently. The standard of cleanliness around the home was poor. Bedrooms were very dusty, and needed vacuuming. The bedrooms contained broken or heavily worn furniture, one vanity unit was damaged, one headboard was not attached to the bed, and no low level lighting was provided. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 19 Spills were noted in all rooms on the paintwork, the ground floor wc was odouress, and soiled. The dining table while in need of replacement would also benefit from a thorough clean. In the ground floor wc, there were no hand towels or hand wash. The bin area at the rear of the home needed to be tidied. Two of the three bedrooms require redecoration. Carpets in all bedrooms require cleaning or replacement, and furniture and bedding in all rooms were heavily worn. The wardrobe in the sleep in room was damaged, and the door could fall off onto someone at anytime. It is required this be repaired or replaced. One of the service users is visually impaired. It was positive that work to source some specific adaptations had commenced, although these had not yet been obtained. There was an unpleasant odour in both the wc and first floor bathroom. The staining around the toilet on the first floor, which possibly contributes to this, requires further exploration, and repair. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 20 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The rota did not identify that adequate numbers of staff were provided, or that all staff had received the required mandatory and service user specific training. Staff recruitment records did not evidence robust checks were made on staff, prior to them starting work in the home. EVIDENCE: The rota shows the majority of day shifts are covered by two staff, and that between 9.30 pm and 8 am one sleep in provides staff cover. Discussion with staff and the manager did not evidence that this would be an adequate ratio to support people to access the community, according to the risks and needs service users are reported to have when in the community. One new staff member has been recruited since the last inspection, and the home has one staff vacancy. Staff cover is provided by a consistent group of people who generally know the service users well. The records of training available in the staff files did not evidence that all staff had received the required mandatory or service user specific training. It is required this be reviewed, and if necessary staff be provided with the training needed. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 21 Recruitment files of four staff were assessed. No file had the full compliment of records as required. The new manager had undertaken supervisions with all staff, and the records of these were detailed. Prior to this some significant gaps between supervisions had occurred. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 22 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, 41, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The management of this home has not ensured that service users needs and wishes are planned for and met. A large number of previously made requirements have been brought forward. EVIDENCE: The manager appeared to be very motivated, and her response to issues raised was positive. The inspector felt confident she would be able to address the shortfalls within the running of this home. It is required that an application for registration be made to the CSCI. The CSCI continues to be concerned about the running of the home, and the welfare of the people accommodated. It is not evident that the level of service offered is consistent with the assessed needs of the service users. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 23 The last inspection was undertaken on January 31 2006, and in the fourteen weeks since that time eight of the twenty-seven-requirements made had been met. Eight requirements have been carried forward for the second time. Caretech commission an external company to undertake quality assurance. This is undertaken quarterly, and was most recently undertaken in March 2006. The manager has drafted some quality questionnaires to be circulated to service users, family and visitors of the home. Record keeping was generally found to be poor. The quality of daily records made requires improvement. The current records give no indication of service users response to care, or satisfaction with the service offered. Specific monitoring such as behaviour and healthcare needs to be reviewed to ensure it is systematic and robust. Records about care need to be in an easy to access format, with duplicate information removed, and clear advice regards needs readily available. Health and safety of service users, staff and visitors had been maintained by the routine testing and servicing of the fire alarm, water supply, hard wiring and gas. Weekly fire alarm tests were overdue, last tested on May 7 2006. The last available PAT tests record was dated September 2004. The fire risk assessment raised concerns regards the evacuation of service users, and the testing of the emergency lighting. The document instructed staff to contact service users family or advocates in the event of them choosing not to evacuate the home. The inspector questions the suitability of this in the event of an emergency. Staff are instructed to test the emergency lights by turning the electric off for one hour. It could not be established if this action would disable the fire alarm, door keypads, and the impact it would have on the phone, cooking, refrigeration and watching TV. It was required this be urgently reviewed. The inspector was concerned to find the kitchen door, and music room door locked with a key. This could impede the safe evacuation of the home, through the fire exit in event of an emergency. An immediate requirement regards this was made. It is recommended that large freestanding pieces of furniture such as wardrobes be attached to the wall. It was positive that new COSHH data sheets had been obtained for products used in the home, however it was of concern that the COSHH cupboard was unlocked. Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 24 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 2 23 2 ENVIRONMENT Standard No Score 24 1 25 1 26 1 27 1 28 2 29 2 30 1 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 2 3 LIFESTYLES Standard No Score 11 3 12 1 13 1 14 1 15 1 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 2 2 1 2 1 X 1 1 X Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 25 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 12 15 Requirement Not met from the previous two inspections. Plans that fully underpin the needs of service users must be developed. Not met from the previous two inspections. Service users must be consulted regarding the development and review of their plan. Goal setting for service users must clearly show: who had set the goals, how they were agreed upon, who is responsible for meeting them, how it will be identified if they are met, when the goal was set, or who the goal is intended for? Matters identified in service users meetings must be explored, and evidence of action taken made available. Care documents must contain clear guidance on how the service user communicates, and any tools or adaptations required regarding this. Not met from the previous inspection. Risks posed by and undertaken DS0000065003.V293609.R01.S.doc Timescale for action 01/09/06 2. YA6 12(2)(3) 01/09/06 3. YA6 12(3) 01/09/06 4. YA8 12(2)(3) 16(2)(m,n) 12(4)(b) 01/07/06 5. YA8 01/07/06 6. YA9 13(4)(a-c) 01/07/06 Kingsbury Road, 228 Version 5.1 Page 26 7. YA9 13(4)(a-c) 8. YA11 12(1)(b) 9. YA14 16(2)(m,n) 12(1)(b) 10. YA15 16(2)(m) 11. YA16YA17 12(1)(a) 12. YA17 17(2) Sch 4(13) 13. 14. YA18 YA18 12(1)(a) 12(1)(a-b) 15 15. YA19 12(1)(a) 13(1)(b) 12(1)(a) 16. YA19 by service users must be assessed, and control measures implemented. Not met from the previous two inspections. Risk assessments must be developed to enable service users development. Not met from the previous two inspections. Opportunities for service users growth and personal development must be included in their individual plan. Access to community activities must be increased. Service users must have access to a range of community activities of their choice. Service users must be offered support to stay in touch with their family, at the frequency, and times they identify. The use of melamine cups and crockery must be reviewed and risk assessed. Where possible service users must be supported to utilise crockery. A record of food eaten by service users must be maintained in enough detail to establish if an adequate and varied diet is being offered. Service users must be offered opportunity to undertake personal care when required. Not met from the previous two inspections. Care documents must provide staff with specific information on how to meet service users personal care needs. Service users must be offered access to routine health care, and a record of such maintained in the home. Monitoring of service users health, and behaviour must be DS0000065003.V293609.R01.S.doc 01/07/06 01/08/06 01/07/06 01/08/06 01/07/06 01/08/06 09/06/06 01/07/06 01/07/06 01/07/06 Page 27 Kingsbury Road, 228 Version 5.1 undertaken is required. 17. 18. YA19 YA19 Health Action Plans must be offered to service users. 12(1)(a) Not met from the previous two inspections. 13(1)(b) Care documents must provide clear guidance on how all health care needs are to be met. 13(4 a-c) Difficult to manage behaviour 13(6) must be risk assessed and planned making reference to DOH guidance on physical interventions. . 18(1)(a,c,i) Staff must be provided with training to enable them to meet service users needs. 13(2) Only one MAR Chart is to be in operation for each prescribed medicine. 22 Action taken in response to complaints must be maintained in the home. 13(6) Property lists and rationale for discarding of valuables and property must be maintained in the home. 13(6) Staff must ensure they protect service users interests’ regards spending of their personal finances. 13(6) Accurate records of money and expenditure must be held in the home. 13(6) Partly met (Element met deleted) The adult protection policy must be reviewed and developed to ensure staff are instructed to make the service user safe, and to contact social care and health. 13(6) Unmet from the last inspection. All incidents of service user to service user abuse must be reported under adult protection procedures. 23(2)(b) Partly met. (Elements met have DS0000065003.V293609.R01.S.doc 12(1)(a) 01/09/06 01/08/06 19. YA19 01/08/06 20. 21. 22. 23. YA19 YA20 YA22 YA23 01/09/06 01/07/06 01/08/06 01/08/06 24. YA23 01/07/06 25. 26. YA23 YA23 09/06/06 01/08/06 27. YA23 09/06/06 28. YA24 01/09/06 Page 28 Kingsbury Road, 228 Version 5.1 29. 30. YA26 YA29 23(2)(b) 23(2)(n) 31. 32. YA30 YA30 23(2)(d) 23(2)(d,p) 33. 34. YA30 YA33 16(2)(j) 18(1)(a) 35. 36. 37. YA34 YA37 YA41 19 8 9 37 38. YA41 17 been deleted) Décor and furniture throughout the home must be updated and replaced where broken and worn. (This includes the bathroom, toilet, front door and windows, sleep in room wardrobe) Décor, flooring and furniture in service users bedrooms must be improved. Products explored, but not yet obtained. The provision of adaptations to support people with sight impairment must be explored and obtained if required. All areas of the home are to be maintained in a clean condition. Not met from the previous two inspections. Odour management must be improved in the first floor bathroom. Hygienic hand wash and dry facilities must be provided at all communal sinks. Not met from the previous two inspections. The number of staff provided must be adequate to enable service users to undertake activities of their choice, consistent with their peers. All recruitment records must be available for all staff employed at the home. The manager must make application to the CSCI for registration. Unmet from the previous inspection. The CSCI must be informed of all reportable incidents under regulation 37. The quality of daily records must be reviewed and improved. DS0000065003.V293609.R01.S.doc 01/09/06 01/08/06 09/06/06 01/07/06 09/06/06 01/07/06 01/07/06 01/07/06 09/06/06 01/07/06 Kingsbury Road, 228 Version 5.1 Page 29 39. 40. YA42 YA42 23(4)(c)(v) 23(2)(c) 41. YA42 23(4)(a) 42. YA42 23(4)(b) 43. YA42 13(4)(a) Fire alarms must be tested weekly and a record of tests maintained in the home. Portable Appliance Tests (PAT) must be undertaken, and a record of this maintained in the home. The fire risk assessment must be reviewed, and the procedure for evacuation, and testing emergency lighting improved. Adequate routes of escape must be provided from the home, and locks on the kitchen and music room door must be reviewed. Substances harmful to health (COSHH products) must be stored in a locked cupboard. 09/06/06 01/07/06 09/06/06 09/06/06 09/06/06 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. 2. 3. 4. Refer to Standard YA20 YA24 YA41 YA42 Good Practice Recommendations It is recommended that a sample signature list be maintained in the medication record. It is recommended that homely touches be used to finish off the lounge room. It is recommended that the arrangement of service users files be reviewed and that information be stored and presented in an easy to access and understand manner. It is recommended that wardrobes be attached to the wall Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 30 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 Kingsbury Road, 228 DS0000065003.V293609.R01.S.doc Version 5.1 Page 31 - 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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