Inspection on 29/06/07 for Manor Park Grove, 25

This inspection was carried out on 29th June 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Grove, 25 23/05/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Manor Park Grove, 25 Northfield Birmingham West Midlands B31 5ER Lead Inspector Kerry Coulter Key Unannounced Inspection 29th June 2007 09:30 Manor Park Grove, 25 DS0000016796.V341898.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.V341898.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.V341898.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.V341898.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 2006 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 standard fee for the home is £873.05 variable depending on people’s needs. This does not include transport, leisure activities and toiletries. Holidays up to £300 are covered. Copies of inspection reports are available to read at the home on request. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2007 to 2008. A random inspection was undertaken in January 2007. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a pre inspection questionnaire (AQAA). All people who live at the home were spoken to. Due to their communication needs most people who live at the home were not able to comment on their views. Therefore to establish what it is like to live at the home time was spent observing care practices, interactions and support from staff. However the duration for this was limited as people who live at the home were out for most of the day. Discussions with staff took place, the Manager was not at the home during the visit. 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. 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. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some care plans and risk assessments needed improvement so that people’s manual handling and healthcare needs are met. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 7 Ensure people’s capacity to refuse medical treatment is assessed and action is then taken in the person’s best interests depending on the result of the assessment. Ensure that people at the home have all the mobility aids they need so that the risk of injury is reduced and people are assisted to move safely. The shower room must be redecorated and refurbished so that it is a safe, homely and comfortable place for the people living there to spend time in. Thorough checking of new staffs employment history needs to be done. This would show that all the necessary checks had been done to make sure that suitable people are employed to work with the people living there. The Manager must ensure staff have all the training and support they need to do their job and to support the people who live in the home. There should be an audit of the home and the people living there and their representatives should be asked their views on how the home should be run. This will make sure that the home is run in the way they want it to be. 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. A review of the current management arrangements of the home is needed to ensure the home is effectively managed. 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.V341898.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.V341898.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 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to ensure they can make a choice about whether or not they want to live at the home. 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. The AQAA questionnaire completed by the Manager records that the home intends to produce an audio version of the service users guide. There have been no new people admitted into the home since the last inspection. The Team leader said that there had been some referrals but the initial assessment had shown that the home could not meet the individuals needs. As identified at previous inspections the home’s admission policy needs review as it has been in place a number of years, this will ensure it reflects current good admission practice. Since the last inspection new terms and conditions have been produced, these included information on fees. The Assistant Team Leader said that each person Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 10 living had at the home had their own copy. This ensures people have information about the terms and conditions of their stay at the home. Manor Park Grove, 25 DS0000016796.V341898.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, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff generally have the information they need so they know how to support the people living in the home. Risk assessments need to be kept under regular review to ensure that risks to people living in the home are managed in a safe and responsible manner. EVIDENCE: The care provided to two people who live at the home was case tracked. This included sampling of their care plans and risk assessments. Some good work was being done by staff in completing person centred plans; these were called ‘Essential Lifestyle Plans’. Care plans detailed how staff are to support people to meet their communication, social, cultural, spiritual, health, personal care, dietary and mobility needs. They also stated what the person’s preferences, likes and dislikes were. The care plans sampled were generally detailed in content and had both been reviewed in the last six months. For one person whose needs had recently changed their plans regarding mobility needed review to reflect the additional support they sometimes now Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 12 need from staff. Their care plan also commented they may be at risk from pressure sores but there was no care plan available for pressure care to ensure the person receives the care they need. This is further detailed in the health care section of this report. Since the last key inspection a system of key worker reviews has been introduced. It is intended that these will be completed monthly but currently the frequency of the reviews is variable. Each person’s records included individual risk assessments. These covered areas such as crossing roads, handling money, using the kitchen, fire and manual handling but an assessment was not available for the individual recorded as being at risk of pressure sores. 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 reviewed in April or May. However one person has had a change in needs and so their manual handling assessment requires updating to reflect that staff sometimes need to assist him to get up from the floor and use his wheelchair in the home. Manual handling assessments have been seen to need review at the previous inspection. 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. Staff said and daily records showed that people who live at the home are consulted in planning the menu. Staff gave examples of how people had participated in choosing new décor for the shower room. One person has recently refused two blood tests but it is unclear if they have the capacity to make this decision and understand the implications of refusing the test. The Community Nurse has recommended a referral to an advocate. An assessment needs to be undertaken on the individual’s capacity to make this decision. Discussion with staff indicates they were unaware of the new Mental Capacity Act and its implications for people who live at the home. Manor Park Grove, 25 DS0000016796.V341898.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 for activities ensure that people living in the home experience a meaningful lifestyle. The people living in the home are offered a healthy diet to ensure their well being. EVIDENCE: Opportunities for activities for people to participate in have improved as activities are now better planned with each person having their own schedule. Records and discussions with staff show that activities on offer include visits to the pub, cinema, eating out, church, massage, church lunch club, Cannon Hill Park and games such as Jenga or Connect 4. Some people also attend day centres. One person has sometimes refused to participate in activities but staff have kept good records of all the activities they have tried to offer. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 14 People have opportunities to participate in activities on an individual basis as well as a group. It was nice that the hallway had a gallery of photographs of people who live at the home and staff enjoying leisure activities outside of the home. Staff said one person supports Birmingham City Football Club and will be buying a season ticket and will be supported by staff to attend home games. Staff said this years holiday destinations were currently under discussion, they said people went on holiday last year to Cornwall. The home previously benefited from a small activity room but since the last key inspection the use of this room has changed to an office as the home previously lacked office space. People who live at the home do not have any relatives who have contact with them. 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. Each person has their own individual menu, meals are varied and include the recommended five daily portions of fruit and vegetables, they also guide staff as to the portion size as some people need to lose or increase weight. Adequate food stocks were available and a shopping list pinned to the fridge door showed that more food to include fruit and vegetables were to be purchased later that day. Weekly menus covering a four week period are completed on a Saturday with people at the home. As recommended at the random inspection staff are reviewing how people choose food and have started to take photographs of the meals provided. Manor Park Grove, 25 DS0000016796.V341898.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home receive their medication safely and as prescribed by the GP. Generally people’s health care needs are 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 records showed that people are supported to go to the barbers regularly. Both care plans sampled were very detailed regarding individual’s preferences for personal care, for example it was recorded for one person that they like to listen to music whilst dressing. Each person had an assessment of how staff are to support them with moving and handling. Whilst both assessments had been reviewed in the last couple of months the assessment for one person needed reviewing again as staff needed additional guidance due to them needing more assistance from staff. Their assessment recorded they were able to move around the home without support but daily records showed that recently the use of a wheelchair in the home has sometimes been needed. On Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 16 one occasion this person did not want to go to bed till late. When he then chose to go to bed the records recorded that he had to spend all night in his chair as it would have been difficult for staff on their own to get him to bed. If the manual handling assessment had included guidance on the use of the wheelchair staff would have had guidance on how he could have been supported more effectively. At the last key inspection it was identified that referrals had not been made as needed to other health professionals to include the Speech and Language Therapist (SALT) to assess the risk of choking when eating for one person, and the Occupational Therapist (OT) to assess the moving and handling equipment needed for another person. The random inspection in January found that these referral had been made and the SALT and OT have now visited and completed assessments. The OT had recommended additional equipment that is needed to assist with the moving and handling for one person. Some of this equipment has been obtained but a hoist (for occasional use) is still needed. Since that assessment was completed it has been identified that another person may also need the occasional use of a hoist and an assessment is scheduled by the Physiotherapist. Staff said the delay in getting a hoist was due to funding difficulties but that a quote for the purchase of a hoist had been sent to headquarters. 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 had been unwell over recent months. Their records showed that staff had ensured that the person was referred to a range of health professionals. The care plan for one person briefly commented they may be at risk of pressure sores. Daily records for the day of the inspection visit showed they had two small sores. Staff said the sores had been caused by the incontinence pad. A risk assessment needs to be completed so that the level of risk can be fully assessed and then a care plan completed so that staff know what support and pressure relieving equipment is needed to prevent pressure sores occurring. 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. At the last inspection the home had commenced health action planning, the plans were in various stages of completion. Health action plans are something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. These plans have now been completed. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 17 Medication is stored in a locked cabinet. The home retains copies of prescriptions so that staff can check the correct medication has been received from the chemist. The Assistant Team Leader audits the medication monthly to make sure it has been given correctly. 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. One new staff is assessed as being competent to give medication and is booked to complete more in depth training in August. It is recommended that to ensure people receive medication in a safe manner staff do not administer medication without supervision until after they have completed the training. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 18 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 adequate. 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 generally sufficient to ensure that the people living in the home are protected from abuse, neglect and self-harm. EVIDENCE: There had been no complaints received by the home or the CSCI in the last twelve months. The complaints procedure is included in the service user guidebut it would be of benefit if it was also on display so that visitors to the home are made aware of the procedure. People have an addressed card located in their bedroom that they can post to a FCH manager if they have any complaints, however due to peoples needs they would need support from someone else to do this. The majority of staff have had training in protecting people from abuse and for those staff that need to do the training it is booked for August. Staff have not had training in the Mental Capacity Act, this Act provides a statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. It was identified at the last inspection that a new format was in place for the recording of people’s personal belongings but records sampled at this visit showed the new system was not yet in use. The inventory for one person had not been updated since 1998. These records need to be kept up to date so that staff know if possessions go missing. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 19 The financial records for two people who live at the home were sampled; receipts were available for all expenditure. 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. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 20 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, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made but arrangements are not yet sufficient to ensure that people live in a home that fully meets their needs. EVIDENCE: Since the last key inspection some repainting of communal areas to include the kitchen has taken place. The hallway is now more homely without the clutter of general notices and rotas on display. As identified at the random inspection in January the shower room requires redecoration and repair to areas where water has been seeping through the join in the flooring and tiling. This seepage has caused tiles to keep falling off the shower room wall and has damaged some areas of new paintwork in the hallway. The Assistant Team Leader said that they were still awaiting a date for the refurbishment of the shower room but they have chosen the new décor from samples- to include new flooring. She said staff had sat with people who live at the home to help them choose what they liked. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 21 The office has been moved since the last key inspection from a room that was very cramped into what was the home’s activity room. The former office is being used to store equipment. This has reduced the communal space for people who live at the home. The home has a combined lounge/dining area, which is the only shared space available. There is no communal space for people to receive visitors, take part in activities or have space away from other people. Bedrooms seen were well decorated according to individual’s tastes, interests, age and gender. They contained many personal possessions and staff said that people had been involved in buying things for their bedroom. The home was clean and free from offensive odours. Satisfactory hand washing facilities were observed in the bathroom, laundry and kitchen. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are generally sufficient to ensure that there is enough staff to ensure people’s needs can always be met. Staff do not receive all the appropriate training to meet individuals needs. People living there are not fully 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. Inexperienced staff have the opportunity to undertake the Learning Disability Award Framework (LDAF). The AQAA stated that two staff have completed an NVQ in care and two staff are currently undertaking an NVQ. To ensure people are supported by a qualified staff team at least 50 of staff need to achieve an NVQ. The home currently has a small staff team as there are some staffing vacancies. Staff said that the Manager had recruited a new member of staff the previous week and was interviewing more candidates that day. The rota showed that staffing levels have been maintained by staff working extra hours or casual staff being used. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 23 Since the last inspection staff have done training in epilepsy so that they have the knowledge they need to meet the needs of people at the home who have epilepsy. However staff have not had any training on dysphasia (eating / swallowing problems) despite one individual assessed as having dysphasia. Discussion with the Assistant Team Leader indicates this training has not been scheduled for staff. Most of the staff had done fire, medication, adult protection and food hygiene training. Only two staff had done first aid training but three additional staff are booked to do this in August. Three staff were booked to do manual handling training in August but refresher training is needed for other staff at the home. Discussion with staff indicates that there is not a training plan in place for casual staff. This means that people at the home are supported by casual staff who often have not done all the training they need to enable them to safely meet people’s needs. As the Manager was not on duty during the visit it was not possible to look at staff recruitment records. Following the visit evidence of the recruitment procedure followed for one new staff was forwarded to the CSCI. These records showed that an application form had been completed and two written references, proof of identity and a Criminal Record Bureau check had been obtained. However some improvement is needed to make sure the recruitment procedure is robust and protects people living at the home. The application form for the member of staff only recorded their work history back to 2005, despite the form asking for a full history. There was no evidence that it had been explored with the staff what they were doing prior to 2005. Minutes show that staff meetings are held monthly. Records sampled and discussions with staff show that staff had received regular formal, recorded supervision sessions. Reserve staff also receive supervision. This ensures staff get the support they needs and identifies their training and development needs to ensure they can meet the needs of the people living in the home. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 24 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, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements of the home require review to ensure the home is effectively managed. The views of people who live at the home do not underpin all self-monitoring, review and development by the home. Arrangements to ensure that the health, safety and welfare of people is promoted and protected are variable. 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. 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. Evidence from this inspection shows that whilst some outcomes for people have improved there are other areas that have been previously identified as needing improvement that have been slow in the progress made. The slow progress may be in part due to the fact that the Manager has responsibility for Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 25 managing two separate homes. It may be more effective if the home had its own manager who was able to concentrate on the improvements needed, or perhaps the role of the Assistant Team Leader could be developed and they worked off the care rota. Discussion with the Manager following the inspection indicates that he has not kept himself fully up to date with issues of good practice, for example he had not heard of the Mental Capacity Act that came into force in April 2007. The Manager was not on duty at the time of the visit. The staff rota for the home did not record the hours worked by the Manager. Staff said the Manager was at FCH headquarters interviewing potential new staff. Staff said that if they want to know when the Manager is going to be on duty they check with the home up the road which he also manages. The Manager should record his hours on the home rota so that staff do not have to rely on contacting another home for information. The home does have policies and procedures in place for quality assurance but the tools recorded in the policy are not all put into practice. Further work is needed to ensure a working quality assurance system is in place. The Manager said at the inspection in 2006 that Quality Assurance is a key theme for development within FCH in 2006, however progress in this area is slow. The Assistant Team leader said that FCH are now looking to buy in a quality assurance package. What has improved since the last inspection is that a service development plan has been completed. This recorded some key objectives for the home to include minimum community activity levels, obtain manual handling equipment, establish local quality audits and apply for funding for a conservatory. A representative from FCH, the Provider visits the home monthly and writes a report of their visit as required under Regulation 26. The reports were not available in the home, the Assistant Team Leader said that following requirements made at the random inspection the area manager had taken the reports away to audit them to see which reports were missing. Following the inspection visit copies of the reports were sent to the CSCI and showed that visits are undertaken monthly. 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 West Midlands Fire Service visited the home in December 2006 and said that the fire precautions were satisfactory. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 26 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 February 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. As stated in earlier in this report not all staff have had regular manual handling training to ensure that they know how to move people safely and reduce the risk of accidents. A hoist also needs to be purchased without delay so that people at the home and staff are not put at risk of injury through inappropriate manual handling. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 27 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 2 3 X 4 X 5 3 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 2 25 X 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 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 2 2 3 X 2 X 2 X X 2 X Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15(2)(b) Requirement Ensure that where people’s needs have changed the care plan is updated to ensure staff provide the care people need. Ensure manual handling assessments are subject to regular review and detail how staff are to assist in transferring people or assisting them to stand from the floor so that the risk of injury to people is reduced. Outstanding requirement from 30/08/06. Where people have been identified at being of risk of pressure sores ensure a full assessment is completed and a care plan put in place so that people get the care they need to stop pressure sores developing. Repairs and redecoration are required in the shower room to ensure the home remains a nice place for people to live. DS0000016796.V341898.R01.S.doc Timescale for action 30/08/07 2 YA18 13(4) 30/08/07 3 YA19 15(1) 30/08/07 4 YA24 23(2) 30/09/07 Manor Park Grove, 25 Version 5.2 Page 29 5 YA35 18(1)(c) 6 YA37 10(1) 7 YA39 24 Outstanding requirement from 30/03/07. Ensure that staff have had all the training they need to meet the needs of people who live at the home, to include dysphasia training. A review of the current management arrangements of the home is needed to ensure the home is effectively managed. A formal quality assurance system must be in place that seeks the views of people at the home, their representatives and other stakeholders. 30/09/07 30/09/07 30/09/07 8 YA42 13(4)(c) 9 YA42 23(2)(n) Outstanding requirement from 30/04/06. All staff who undertake 30/09/07 manual handling (to include casual staff) must have regular manual handling training so that people who live at the home and staff are not put at risk of injury through poor manual handling practices. Ensure that people at the 30/08/07 home have all the mobility aids they need so that the risk of injury is reduced and people are assisted to move safely. Outstanding from 30/09/06. Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 30 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 YA2 Good Practice Recommendations The admission policy and procedure requires review to ensure it reflects the National Minimum Standards with regards to the admission and assessment process to ensure good outcomes for people who are considering moving in to the home. Ensure people’s capacity to refuse medical treatment is assessed and action is then taken in the person’s best interests depending on the result of the assessment. It is recommended that to ensure people receive medication in a safe manner staff do not administer medication without supervision until after they have completed the training. Staff should receive training in the new Mental Capacity Act, so that they have an understanding of the statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. An inventory of people’s belongings should be kept and regularly updated when items are bought or are discarded. This will enable staff to know if people’s possessions go missing. 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. Develop a training plan for casual staff that work at the home to ensure they receive all the training they need to meet people’s needs safely. Review recruitment procedures to ensure that the previous work history of potential staff is fully explored to include any gaps in employment. The Manager of the home must ensure he keeps himself up to date with areas of current good practice so that he has the knowledge he needs to ensure good outcomes for people at the home. 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. 2 3 YA7 YA20 4 YA23 5 YA23 6 YA28 7 8 9 YA35 YA34 YA37 10 YA37 Manor Park Grove, 25 DS0000016796.V341898.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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.V341898.R01.S.doc Version 5.2 Page 32 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!