Inspection on 23/05/08 for Manor Park Grove, 25

This inspection was carried out on 23rd May 2008.

CSCI found this care home to be providing an Good service.

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

Manor Park Grove, 25 29/06/07

Manor Park Grove, 25 29/06/06

Manor Park Grove, 25 23/01/06

Manor Park Grove, 25 06/09/05

Manor Park Grove, 25 13/10/04

Manor Park Grove, 25 28/04/04

Manor Park Grove, 25 12/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Manor Park Grove, 25 Northfield Birmingham West Midlands B31 5ER Lead Inspector Kerry Coulter Key Unannounced Inspection 23rd May 2008 09:00 Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 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 Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 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. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Park Grove, 25 Address Northfield Birmingham West Midlands B31 5ER 0121 476 2703 F/P 0121 476 2703 griffhughes@fch.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Friendship Care and Housing Association Mr Griffith Hughes Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years The home can continue to accommodate one named service user over the age of 65 with a learning disability. Future admissions and the Statement of Purpose be amended to reflect the age of the service users accommodated. 29th June 2007 Date of last inspection Brief Description of the Service: 25 Manor Park Grove is a purpose built bungalow, which provides accommodation for four men with learning disabilities. It is owned by FCH Housing and Care. The home is situated within a residential housing estate on the site of an old hospital. The home is situated within a cul-de-sac with off road parking. There are local bus services available. Each person who lives at the home has a single room with a wash hand basin, which have been decorated to individual preferences. The bathroom has an assisted bath, which has the advantage of automation if required, to assist people with limited mobility. In addition to the bathroom the home has a shower room. To the rear of the home there is a garden. The service user guide stated that the standard fee for the home is £873.05 variable depending on people’s needs. This does not include transport, leisure activities and toiletries. This information was correct at the time of inspection so the reader may wish to contact the care home for up-to-date information. Copies of inspection reports are available to read at the home on request. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. One inspector carried out the visit over one day; the home did not know we were going to visit. This was the homes key inspection for the inspection year 2008 to 2009. The focus of inspections we, the commission, undertake is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and the annual quality assurance assessment (AQAA). Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. Some of the people who live at the home were not able to tell us their views because of their communication needs. Time was therefore spent observing care practices, interaction and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: Staff were observed to give support with warmth, friendliness and patience and treat people respectfully. The people living there were asked what they wanted to do and where they wanted to go. Staff offered them choice throughout the day and supported them to do the things they wanted to do. Each person living in the home has a care plan so that staff know how to support them to meet their needs and goals. People living in the home often go out and do the things they enjoy doing. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 6 There is a choice of healthy food so that people are supported in their diet to keep well. The systems for medication administration ensure people receive the medication they need. Staff at the home seek input from other health and social care professionals to assist in meeting peoples health needs. Considerable effort has been made to personalise people’s bedrooms to reflect their personal tastes and interests. People were well dressed in good quality clothes that were appropriate to their age, the weather and the activities they were doing. Regular health and safety checks are done to make sure that equipment is well maintained and does not put the people living there at risk of harm. What has improved since the last inspection? What they could do better: Some care plans and risk assessments needed improvement so that people’s needs are met. Where routines are affected by the needs of staff, ie the times people are supported to change into their pyjamas, people need to be consulted. Their agreement should be recorded in their care plan. Some repairs should be done so the house is comfortable and safe to live in. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 7 Consideration should be given to providing more communal space so that people who live at the home have an additional room to spend time away from other people, meet with visitors or carry out activities. Casual staff that work at the home need more training to ensure they meet people’s needs safely. The electrical contractor should be contacted to chase up the electrical certificate for the home so that the manager can be sure the electrical installations are in a safe condition. 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. The summary of this inspection report can be made available in other formats on request. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 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 Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that prospective residents have the information they need to make a choice about whether or not they want to live there. Arrangements are in place to ensure that before people move into the home an assessment is completed to ensure their needs can be met. EVIDENCE: It was observed that the Statement of Purpose and Service User Guide documents are readily available in the home. These documents had been updated and included all the relevant and required information. The service user guide was in an easy read format that included pictures. This gives the information about what the home provides to people who are looking to see if the home can meet their needs and whether or not they want to live there. Records showed that a copy of the service guide had been provided to a new resident and his relative so they could make a decision if the home was suitable. At the last inspection the manager said that the home intended to produce an audio version of the service users guide. The annual quality assurance assessment completed by the manager stated that this was still to be done. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 10 One new person who had been admitted to the home since the last inspection was case tracked. An assessment had been obtained from their social worker prior to them moving in, and the home had also completed their own assessment to make sure they could meet the person’s needs. Records and discussions with staff showed that the person and their relative had visited the home prior to him moving in. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have most of the information they need to support individuals to meet their needs and ensure their safety and well being. The people living there are usually supported to make choices and decisions about their day – to - day lives. EVIDENCE: The care provided to two people who live at the home was case tracked, to include one person who had lived at the home for only three weeks. Each person had an individual care plan, which detailed how staff are to support the individual to meet their needs and achieve their goals. Care plans stated the likes and dislikes of the person so that staff know what the person wants. Care plans detailed how staff are to support people to meet their communication, social, cultural, health, personal care, dietary and mobility needs. The care plans sampled were generally detailed in content although one was overdue for review to make sure the information was up to date. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 12 One person has limited verbal communication and so uses some signs to communicate. It is good that to enable staff to know what the person is saying a communication guide has been produced that has actual photographs of the person using the signs with a written translation. One person needed to drink lots of water due to a health condition and staff spoken with were aware of this. Staff said that this person was reluctant to drink and so a fluid chart had recently been introduced to monitor how much they were drinking. It is recommended that the care plan for this person guides staff in more detail how to encourage the person to drink more so that they do not become ill. Members of staff were observed encouraging people to make choices about day-to-day matters, such as what to have to drink and what they wanted to do on that day. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. Where people have been unable to make their own decisions about important issues, for example health care, the home had obtained the services of an advocate for the person. Staff said and daily records showed that people who live at the home are consulted in planning the menu. One person who had recently moved into the home said he had been consulted about what colour he would like his new bedroom to be painted. Discussion with staff and sampling of records showed that one person was being assisted to get into his pyjamas in the evening by the day staff. This occurred when a night staff who was pregnant was on duty to reduce the manual handling risks to the member of staff. However, there was no evidence that the person had been consulted about this practice as it limits his decisions about the times he can choose to get ready for bed. Each person’s records included individual risk assessments. These covered areas such as handling money, using the kitchen, fire and manual handling. People at risk due to eating problems had risk assessments completed with the involvement of the Speech and Language Therapist. The risk assessments in place were generally detailed and had been regularly reviewed. However some areas of risk had not been reviewed for the person who had recently been admitted to the home. Bed rails were observed to be fitted to their bed and staff confirmed they were used at night, but there was no risk assessment on their use. The manager said that the person had brought the bed from their previous home and so he had assumed they were safe. The manager said he would ensure the assessment was completed. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that the people living there experience a meaningful lifestyle. People are offered a healthy diet that ensures their health and well being. EVIDENCE: Each person who lives at the home has their own schedule of activities. Records and discussions with staff show that activities on offer include visits to the pub, cinema, eating out, church, massage, church lunch club, bowling, Cannon Hill Park. Recently everyone went to the theatre to see Dr Doolittle which staff said they enjoyed. One person said he was looking forward to going out later that day, he said he liked living at the home as he did things like bowling. He said he liked this home better than his last one. Everyone went out on activities during the Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 14 inspection visit, one person went to the day centre whilst others went out shopping or to the bank. People are encouraged to participate in planning what activities they would like to do. Staff are currently developing a photographic activity record to make it easier for people to see the photographs of the activity and make a choice of what they would like to do. Most people who live at the home do not have any relatives who have contact with them. Staff meeting minutes record that staff have attempted to make contact with the brother of one person at the home by writing to his last known address but have had no response. Staff are going to contact social services to see if they can help with the search. Discussion with the manager and staff indicate that efforts to encourage friendships is made. For example people from a nearby home sometimes visit for tea and vice versa. Food provided and menus are appropriate to and reflect the cultural background of the individuals who live in the home. Plentiful supplies of fresh fruit and vegetables were seen in the home. Each person has their own individual menu, meals are varied and include the recommended five daily portions of fruit and vegetables. Weekly menus covering a four week period are completed on a Saturday with people at the home. One person spoken with said that food at the home was ‘good’. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health care needs are usually recognised and responded to ensuring that their health is promoted. EVIDENCE: The people living in the home were well dressed in clothes that were appropriate to their age, the weather and the activities they were doing. Attention had been paid to individual’s appearance and care plans included good detail about what support the person needed with their personal care. Each person had an assessment of how staff are to support them with moving and handling. One person has been assessed by the Speech and Language Therapist as having dysphasia (swallowing difficulties) staff spoken with were aware of the needs of this person and that food needed to be blended and drinks thickened. One person is a wheelchair user and had a cushion on their wheelchair and a special mattress on the bed for the prevention of pressure sores, however there was no assessment of the risk of pressure sores occurring. Discussion Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 16 with staff and the manager indicates that the person who has not lived at the home long had not had any red or sore areas of skin since admission to the home. A risk assessment should be completed so that the level of risk can be fully assessed and then if necessary, a care plan completed so that staff know what support is needed to prevent pressure sores occurring. Records sampled included individual health action plans. This is a personal plan about what a person needs to be healthy and what healthcare services they need to access. Records sampled of the people who live there showed that other health professionals are involved in the care of people to ensure that their health needs are met. Records showed that people had regular check ups with the dentist, optician and chiropodist where appropriate. Medication is stored in a locked cabinet, the location of this has recently changed on the advice of the pharmacist due to it being too warm. The home retains copies of prescriptions so that staff can check the correct medication has been received from the chemist. . Three people’s Medication Administration Records (MARS) were sampled and these showed that medication had been given as prescribed. Protocols were in place for people who were prescribed PRN (as required) medication, these had been agreed with the GP. These stated when, why and how much of the medication should be given. Medication competence assessments are completed for all staff who administer medication, this includes observation of staff giving medication and staff having to complete questions on medication practice. Unfortunately one person who lived at the home has died since the last inspection. They had been in hospital for some time and it is good that staff visited them regularly whilst they were there. The home ensured that the person had an advocate whilst they were ill due to their lack of capacity to make some decisions. Discussions with the manager indicate that staff and people who live at the home attended the person’s funeral. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure, which ensures people’s views are listened to and acted upon. Arrangements are sufficient to ensure that the people living in the home are protected from abuse, neglect and selfharm. EVIDENCE: The complaints procedure is included in the service user guide and was also on display so that visitors to the home are made aware of the procedure. The procedure is in an ‘easy read’ format that includes pictures so making it easier to understand. We have not received any complaints about this service in the last 12 months and the home had not received any. One person who lives at the home said he did not have any complaints. There have been two adult protection referrals since the last inspection, one involved the alleged behaviour of a staff towards another and did not involve people who lived at the home directly. The second incident involved an allegation that one person had been neglected resulting in ill health. A meeting was chaired by social services, the outcome was that the home was not at fault. The financial records for one person who lives at the home was sampled; receipts were available for all expenditure. However the checking of the receipts took some time as lots of receipts were kept loosely in a plastic sleeve. Clipping the receipts together month by month would make auditing Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 18 them much easier. Staff check monies at the handover of each shift to ensure that the money is still there and any money taken out for people to spend had been calculated properly. Staff training records and discussion with staff showed that they have received training in the Protection of Vulnerable Adults (POVA) so they know how to identify different types of abuse and what to do if abuse is happening so they can protect the people living there. Some staff have also had training in the Mental Capacity Act. This came into force in April 2007 and is about assessing each person’s capacity to make decisions so it is important that staff know about this. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure people live in a homely, comfortable and safe environment. EVIDENCE: The home was generally homely in style and well maintained. The home has a combined lounge/dining area. There is no communal space for people to receive visitors, take part in activities or have space away from other people except for their bedroom. Since the last inspection the furniture in the lounge has been rearranged, this has resulted in some areas of the carpet that has faded over time becoming more obvious and so does not make the lounge area look well maintained. The position of the television and one of the settees means that people using the settee would not be able to see the television. The dining area appeared well maintained, the manager said that the dining tables and chairs were new. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 20 At previous inspections it was identified that the shower room required redecoration and repair to areas where water had been seeping through the join in the flooring and tiling. This has now been completed and the hallway has also been repainted where the water seepage had damaged the plaster. In the bathroom the light fitting was observed to be cracked and discoloured, this needs to be replaced to ensure it is in good condition. Two bedrooms were seen, both were generally in good decorative order and personalised according to individual’s tastes, interests, age and gender. One person really likes football and their bedroom was seen to have lots of football posters on the walls. The manager said that the bedroom of the recently admitted person was due to be decorated in colours that he had chosen for himself. The home has a pleasant enclosed rear garden. It had been improved since the last inspection by painting the seating and fences a bright colour and planting more flowers. Records showed that one person who lives at the home had been involved in deciding where the new plants should go. Observation of the home and discussion with staff indicates that people have the specialist equipment it needs. Grab rails are fitted in the bathroom an shower room to assist people who have mobility needs to be as independent as possible. The bath has an electric bath chair so that people who have mobility difficulties can have a choice of having a bath instead of a shower if they wish. A mobile hoist has been obtained following assessment by an occupational therapist so that staff can safely assist one person to get in and out of bed. Satisfactory hand washing facilities were observed in the bathroom, laundry and kitchen. The kitchen was seen to be clean but the worktops had two damaged areas adjacent to the sink. These damaged areas would not be able to be cleaned properly and so need repair or replacement to ensure good infection control. The home was clean and free from offensive odours making it pleasant to live in. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a competent staff team that can support them to meet their individual needs and achieve their goals. People are protected by the home’s recruitment practices. EVIDENCE: During the visit staff were observed to give support with warmth, friendliness and patience and treat people respectfully. New staff have the opportunity to undertake the Learning Disability Award Framework (LDAF). Two staff at the home have a national vocational qualification (NVQ) at level 2, the deputy manager has level 4. This means that 50 of the staff have an NVQ to ensure that they have the skills and knowledge to work with the people living there. The annual quality assurance assessment completed by the manager indicates that the home aims to improve the number of staff who have this qualification. The home currently has a small staff team as there are some staffing vacancies. The manager said that a new staff had been recruited but had not started work due to the receipt of poor references. The rota showed that staffing levels have been maintained by staff working extra hours or casual Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 22 staff being used. There is some use of agency staff but the home tries to use regular staff. There are a minimum of two staff on duty during the day and one night waking night staff. Staff spoken with said there were enough staff to meet the needs of people at the home. However the home has only three people living there at present and staffing levels will need review should a new person move in. Discussion with the manager indicates that no new staff had started work in the home, with the exception of a member of staff who had transferred from another FCH home on the same road. Recruitment records for three staff were sampled, these showed that checks are done before staff start work to include obtaining references and a criminal record bureau check. This ensures that ‘suitable’ staff are employed to work with the people living there. Sampling of records and discussion with staff shows that permanent staff receive the training they need to meet peoples needs. Staff have had training in fire, adult protection, epilepsy, medication, food hygiene and first aid. Recently staff have had training in dysphagia (swallowing difficulties), the mental capacity act and hoist training. However due to having staff vacancies people are often supported by casual staff, some of whom have not had all the training they need. At the last inspection it was recommended that a training plan was introduced for casual staff. The manager said that the home has tried to do this but has had difficulties in getting casual staff to attend the training. Staff spoken with, including a reserve member of staff said that they had regular supervision and felt supported in their role. The annual quality assurance assessment recorded that each staff also has an annual development review. Regular staff meetings take place so that staff are updated with people’s changing needs and are aware of policies and procedures in the organisation. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that the people living in the home generally benefit from a well run home. EVIDENCE: The Manager is registered with the CSCI and is experienced in working with individuals who have a learning disability and has previous management experience. At the last inspection there were some concerns that the manager had not kept himself up to date with some areas of care practice, this has now improved. Staff spoken with said that the Manager was very open in his approach and you could raise any issues with him that you wanted to. The staff rota for the home did not record the hours worked by the manager. Staff said that the manager lets them know when he will be working or else they can contact the FCH home on the same road that he also manages. The Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 24 manager should record his hours on the home rota so that staff do not have to rely on contacting another home for information. A representative from FCH, the Provider visits the home monthly and writes a report of their visit to ensure the home is being well managed. Sampling of the reports shows that the views of people who live at the home and staff are sought as part of the visits. Internally, staff complete a variety of audits to include medication, health and safety, activities and infection control to ensure good standards. It is an improvement that the home has now started to send out surveys to health professionals to get their views on the home. Two recently returned surveys from community nurses were positive and did not raise any concerns. Fire records showed that a risk assessment is in place so that the risks of there being a fire are minimised as much as possible. Staff had regularly had fire safety training. An engineer regularly services the fire equipment to ensure it is well maintained. Regular fire drills are held so that the people living there and staff know what to do if there is a fire. Staff regularly test the fire equipment to make sure it is working. The temperature of the water is regularly monitored to ensure it will not pose a risk of scalding to people. It is good practice that staff also complete a weekly visual check of the building to ensure it is safe. Systems are in place to monitor the temperature of the fridge, these records showed that food is stored at safe temperatures to reduce the risk of food poisoning. A Corgi registered engineer had completed the annual test of the gas equipment in January this year and stated that it was safe to use. A certificate was available for the adapted bath to show it has been serviced and is safe to use. Discussion with the manager and records in the home showed that the electrical installations had been checked at the end of February to make sure they were safe. The manager said that the home had yet to receive the certificate for this but that the electrics had been found to be safe. It is recommended that electrical contractor is contacted to chase up the certificate for the home. Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 X X 3 X Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(4) Requirement Where bed rails are used for people there needs to be a risk assessment in place to ensure people are not put at risk by the rails. Where people may be at risk of developing pressure sores a full assessment needs to be completed, and if necessary a care plan put in place so that people get the care they need to stop pressure sores developing. Timescale for action 30/07/08 2 YA19 15(1) 30/07/08 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 Care plans should be updated at least six monthly to ensure staff have up to date information on how to meet peoples needs. DS0000016796.V365642.R01.S.doc Version 5.2 Page 27 Manor Park Grove, 25 2 YA6 The care plan for one individual with regards to his need to drink lots of fluids should be updated to guide staff as to how best to do this. This will help ensure the person has enough to drink to stay healthy. Where routines are affected by the needs of staff, ie re the times people are supported to change into their pyjamas, people need to be consulted. Their agreement should be recorded in their care plan. Consideration should be given to providing more communal space so that people who live at the home have an additional room to spend time away from other people, meet with visitors or carry out activities. Some general maintenance issue need attending to, to ensure the home is in good condition and a pleasant place to live: - the lounge carpet needs replacing - light fitting in the bathroom needs replacing. The damaged worktops in the kitchen need to be repaired or replaced to ensure good infection control procedures. Ensure casual staff that work at the home receive all the training they need to meet people’s needs safely. The staff rota needs to record the hours worked by the Manager so that staff have clear information about when the Manager is next on duty in the home. The electrical contractor should be contacted to chase up the electrical certificate for the home so that the manager can be sure the electrical installations are in a safe condition. 3 YA7 4 YA24 5 YA24 6 7 8 YA30 YA35 YA37 9 YA42 Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Manor Park Grove, 25 DS0000016796.V365642.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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