Inspection on 01/08/06 for Manor Park Grove, 5

This inspection was carried out on 1st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Grove, 5 16/10/08

Manor Park Grove, 5 28/11/07

Manor Park Grove, 5 11/07/07

Manor Park Grove, 5 20/01/06

Manor Park Grove, 5 23/08/05

Manor Park Grove, 5 22/01/05

Manor Park Grove, 5 29/09/04

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, 5 Northfield Birmingham West Midlands B31 5ER Lead Inspector Kerry Coulter Unannounced Inspection 1st August 2006 10:00 Manor Park Grove, 5 DS0000016800.V307396.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, 5 DS0000016800.V307396.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, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manor Park Grove, 5 Address Northfield Birmingham West Midlands B31 5ER 0121 476 5821 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) FCH Housing & Care Mr Griffith Hughes Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 20th January 2006 Brief Description of the Service: 5 Manor Park Grove is a purpose built bungalow located within a quiet residential road, built upon the grounds of Rubery Hill hospital. The home is close to the local facilities of Great Park and Rubery Shopping Centre. The home is situated within a cul de sac with off street parking available. Each tenant has a single bedroom, which have been furnished and decorated to individual taste. Each bedroom has a wash hand basin. There is a communal bathroom with an Aquonova bath and there is a separate shower room. In addition to a through lounge/dining room, there is a kitchen, laundry room and an office. To the rear of the home there is a pleasant garden. The registered provider is FCH Housing and Care and the home currently accommodates four adults with a learning disability. The inspection questionnaire completed by the Manager records that the standard fee is £1135.04, but that fees are negotiated on an individual basis dependent on needs. Copies of reports from the CSCI are available in the office, on request. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. Conversations with some tenants were limited due to their complex needs and limited verbal communication. The inspector met all tenants and time was spent observing care practices, interactions and support from staff. Case tracking of the care provided to two tenants was undertaken. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: Tenants go out regularly if they want to and go to places that interest them and they want to visit. Enough staff are provided so that tenants can be supported appropriately and can do what they choose to do. Tenants are encouraged to do things on their own so that they can be as independent as possible. They help to lay the table, do the shopping and prepare meals. Staff support the tenants to keep in contact with their family and friends through visits, telephone calls and buying cards and gifts for special occasions. Inexperienced staff have the opportunity to undertake the Learning Disability Award Framework (LDAF). Tenants were well dressed in good quality clothes that were appropriate to their age, the weather and the activities they were doing. The home has a satisfactory complaints procedure that ensures complaints are appropriately investigated. Some good work has been done on including one tenant in completing their own risk assessment about them going out without staff support. The risk assessment had been completed in consultation with the individual and was in a format that included easy read text, pictures and photographs so that the tenant could understand it. The diversity needs of tenants are met, staff respect individual gender and cultural needs. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans must be reviewed every six months so that if individuals needs have changed staff know how to support them appropriately. The quality assurance system must be completed to make sure that tenants views help to develop a plan for the home on how to move forward, thereby improving the overall quality of life for tenants who live there. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 7 Minor improvement is needed to the medication administration system to ensure tenants get the medication they need. The carpet in the lounge and dining room needs deep cleaning to remove stains to ensure the room is a pleasant area for tenants. Staff must receive all the training they need to enable them to meet tenants needs. Recruitment systems for new staff must improve so that tenants are not put at risk by having unsuitable people working with them. The frequency of staff supervisions must improve so that staff are properly supported and fully aware of their role in the home. Monitoring of the temperatures for food stored in the fridge must improve so that tenants are not put at risk of food poisoning. The registered provider must ensure that requirements made at previous inspections are met in full. 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. Manor Park Grove, 5 DS0000016800.V307396.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, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Tenants are provided with a copy of the service user guide to ensure they are clear about the services the home provides to meet their needs. The admission policy and procedure requires review to reflect the National Minimum Standards and ensure the process fully determines individual needs and that the home is suitable. EVIDENCE: Since the last inspection in January the Manager has finalised new versions of the home’s statement of purpose and service user guide. Copies of these were forwarded to the CSCI and observed to be satisfactory. Copies of these documents were observed to be available to tenants, and were on display on the hall notice-board. There have been no new admissions since the last inspection. It was required at the last two inspections that the admission policy and procedure required review to ensure it reflects the National Minimum Standards with regards to the admission and assessment process. The policy stated that each service is to have its own admission criteria, however this was not available for this home. This has not yet been reviewed. The Locality Manager stated that the FCH is working on updating many of its policy and procedures. However discussion with the Manager shows that whilst the FCH policy and procedure Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 10 need review he is aware of good practice in the admission process and that any new tenant would need a full assessment, involving them prior to admission. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of tenants have care documents and risk assessments that fully underpin their needs and the risks they face. Tenants are consulted on how they wish care and support to be provided. EVIDENCE: Four tenant care plans were sampled, two in full and two in part. Requirements were made at the last inspection to ensure that all care plans are reviewed at least every six months to ensure that the information about the support individuals need is kept up to date. Three of the care plans had been reviewed recently and the content of the plans was very detailed. The remaining plan was dated 2003 and it was not evident that it had been reviewed since then. The information in this plan was not very detailed. The Manager said that the individual’s key worker was currently in the process of updating the care plan so that it would be up to date and the same standard as the other plans. Care plans sampled had some good information about individual’s diverse needs to include cultural issues. One tenant had lots of information about attending a temple to include times when staff should take them. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 12 Evidence was available to show that review meetings are held on a regular basis for tenants. The minutes for one held in June were sampled, the tenants family had attended this. Some of the agreed actions had been done to include the individual having an eyesight test and attending a well person check. Some other actions had not been done by the agreed date, this included updating the ‘tenant profile’ (care plan) and producing a new activity plan. A useful tool called the ‘six monthly review’ has been introduced since the last inspection. This seeks tenants views and reviews activities they have done or would like to do and sets targets and goals with the tenant. Members of staff were observed encouraging tenants to make choices about day-to-day matters, such as what to have for breakfast, 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. Tenant risk assessments were sampled. These were up to date, and are reviewed six monthly to ensure the information is current and the individual protected. Generally risks were found to be well managed and as previously required assessment of risk had been done for one tenant regarding epilepsy and poor appetite. Some good work had also been done on including one tenant in completing their own risk assessment about them going out without staff support. The risk assessment had been completed in consultation with the individual and was in a format that included easy read text, pictures and photographs so that the tenant could understand it. The tenant said they were very pleased with the systems to help them keep safe, this included a talking watch so they knew the time and a talisman pendant that contained information about their medical needs. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. Tenants are part of their local community and encouraged to engage in appropriate activities. Tenants are offered a healthy diet and enjoy their meals. EVIDENCE: Outcomes for tenants with regard to opportunities to participate in activities were last inspected in September 2005 when outcomes were found to be good. Whilst records and discussions with staff show that tenants do have lots of opportunities to participate in activities, the structure and planning of activities is now sometimes on an ad hoc basis as the activity planners that used to be completed have not been used since April. One staff spoken with said that activities are now generally decided upon on a day-by-day basis. Discussions with tenants and staff show there are lots of activities arranged. It is good that activities are undertaken on a 1:1 basis as well as in groups. Most Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 14 tenants went out on activities at some point during the inspection visit. One went out with the intention of buying a new bin for their bedroom, another was out at the day centre. One tenant was being taken out to shop for food at a supermarket appropriate to their cultural needs. Sampled tenant records show that tenants are offered a wide range of activities appropriate to their preferences, gender age and culture. This includes going to markets, reflexology, shopping, walks, going to pubs, cinema and having their hair and nails done. Some tenants have been on holiday to the Cotswolds, staff said that one tenant will be going on holiday soon whilst another has chosen not to go. Discussion with staff and tenant records showed that they maintain contact with their family and friends. Recently a garden party was held, lots of people were invited to include tenants at other homes, neighbours and relatives. One tenant spoken with said it had been a really good day. For one tenant staff had arranged for their yearly review to be held at their Mothers house due to the mobility difficulties of their Mother. This is an area of good practice as otherwise the tenants relative would not have been able to be involved. There was no evidence of strict house rules. Staff were observed sitting and socialising with tenants. Tenants are able to choose whether or not to spend time with others, or to have private time in their own rooms. They are encouraged to be as self managing as possible, such as looking after their own rooms as best they can, and supported to do this appropriately. One tenant was observed answer the front door and the home telephone. Care plans sampled stated how staff are to support service users to be as independent as possible. Daily records sampled showed that tenants helped to prepare their breakfast and were involved in choosing their own clothes to buy and to wear. One tenant said that they had helped to water the newly planted flower tubs in the garden. Food provided and menus are appropriate to and reflect the cultural background of the individuals who live in the home. Adequate food stocks were available and these included fresh fruit and vegetables. Records show that tenants are having a healthy and balanced diet to include at least five portions of fruit and vegetables each day. One tenant has diabetes and they showed the inspector their own individual menu, they said that the food at the home was good. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care was delivered to a good standard. The quality of plans to underpin this varied, some were not up to date to ensure needs are consistently met in the way tenants prefer or require. The systems for the administration of medication require minor improvement to ensure tenants medication needs are safely met. EVIDENCE: Care plans indicated the degree of assistance required for personal care, this varied form very little such as prompting to full personal support. However, as stated earlier in this report the care plan for one tenant was not up to date and lacked detail. Staff had paid attention to each tenant’s personal care and they looked fresh and clean. When a person needed support to change their clothes staff did this. Tenants were dressed appropriately to their age, the weather and the activities they were doing. Each person had his or her own individual style of dress. Sampled records evidence that where tenants are unwell appropriate medical advice is sought. Health checks with the dentist, general practioner and optician are also arranged as required. One tenant has diabetes, their care Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 16 plan contained some good information for staff so that they know the signs of when this person is unwell and the action they need to take. Monitoring of the weight of tenants was observed to require improvement at the last inspection, as it is important that weight is monitored for tenants who have communication difficulties, suffer from lack of appetite or other medical conditions. Weight loss or gain can be an indicator that someone is unwell. Records show this is now being done. Medication was observed to be stored appropriately. Written protocols to direct staff as to when to administer ‘as required’ medication were observed to be up to date and had been countersigned by the GP. Protocols for medication no longer in use had been retained in the medication file. It is recommended that these are archived to remove the danger of staff seeing these and thinking the medication is still in use giving it to tenants. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Medication competence assessments are completed for all staff who administer medication and medication training has been undertaken by staff. At the last inspection the home has been provided with an updated medication policy, however it did not contain guidance for staff regarding the storage and administration requirements for controlled medication. The Manager said he had not yet received an updated policy. The CSCI has been notified of three incidents involving medication errors since the last inspection these included one where medication was not given at the correct time and another when medication was not available. Whilst the action taken by the home in response to the incidents is appropriate the Registered Provider must ensure that such incidents do not occur again. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Tenants know that they can complain and that matters will be dealt with. The arrangements in place to protect tenants from the possible risk of harm or abuse require improvement. EVIDENCE: It is good practice that tenants have a card located in their bedroom that they can post if they have any complaints. The CSCI has not received any complaints regarding this home since the last inspection. The homes complaint log showed that complaints received are appropriately responded to. One tenant spoken with, who had previously made a complaint said they were happy with the response taken and they considered the matter closed. It was identified at the inspections in August 2005 and January 2006 that staff required training in adult protection. Most of the staff have now done this and places have been booked for staff who still need to attend. The home was observed to have a copy of the Birmingham Adult Protection Multi Agency Guidelines. It was of concern at the last inspection that some staff had received training on personal safety techniques from an organisation that is not accredited with the British Institute of Learning Disabilities. The Manager said that this has been reviewed and this organisation is no longer used. The training department is investigating alternative training providers. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 18 One tenant bruises easily and sometimes has bruises to their legs. To ensure this tenant is protected their care plan gives a clear description of the location of usual bruises and explanations as to how these could occur and what to do if bruises are unexplained. The CSCI has been appropriately notified of unexplained bruising and under adult protection procedures the Manager has also notified the relevant social worker. Recruitment practice does not always ensure tenants are protected, this is further detailed in standard 34. It was identified at the last inspection that the home did not have a suitable system in place to track the personal possessions of tenants. A suitable inventory record has now been introduced. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29, 30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is generally satisfactory and presents as a homely and comfortable environment for the people who live there. EVIDENCE: The home was seen to be generally well maintained, comfortable, and free from odour. Furniture, fixtures and fittings were generally of a good standard and well maintained. The lounge and dining room carpet had one or two stained areas, this will need to be deep cleaned and replaced if the stains cannot be removed. The Manager said that some carpet shampoo had recently been purchased with the intention of cleaning the carpet. The home has a combined lounge/dining area, which is the only shared space available. There is no communal space for service user to receive visitors, take part in activities of have space away from other service users. This is not ideal. Since the last inspection new chairs and a dining table have been purchased. One tenant was very pleased with these as they thought they were much more Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 20 sturdy than the previous ones. During the inspection visit some loose tiles were observed on the laundry wall, later on during the visit the tiles fell from the wall. This was reported to the maintenance person by staff who said that things such as this were usually quickly repaired. Three bedrooms sampled were very personalised, tenants are supported by staff to have a bedroom that reflects their gender, age and culture. In the garden there were several attractive pots and hanging baskets on the patio. This is a place that tenants can enjoy using and garden furniture and parasols were provided. During the inspection visit a representative of FCH was also visiting the home to agree a schedule of redecoration for the home with the Manager. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing the home, their support and development were variable. EVIDENCE: It was noted that both staff and tenants appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. The formal handover between staff at the changeover of shift was observed to be conducted in a professional manner with staff passing on relevant information in a confidential manner. It was good that staff focussed on the positive things that tenants had completed during the day. Three of the twelve staff at the home have completed an NVQ in care. The home therefore does not meet the standard of 50 of staff having an NVQ, however other staff are working towards this. Staff who are new to the home have the opportunity to complete the LDAF – Learning Disability Award Framework so that they gain specific training to help them meet the needs of people who have a learning disability. Observation of the staff rota and discussion with the Manager and staff shows that there are enough staff on duty to meet the needs of tenants. Unfortunately three staff have been on long term sick and this has meant that Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 22 to cover deficits agency and casual staff have been used as well as permanent staff working extra hours. Rotas show that in general tenants have continued to be supported by staff who know them. The recruitment files of three staff were sampled. Most of the information required was available, however the original Criminal Record Bureau (CRB) Disclosures were not there for inspection. Files contained handwritten notes of the CRB number, date and outcome. As FCH has not requested and been granted permission by the CSCI to retain the disclosures at their headquarters they must be available in the home to evidence that robust recruitment checks have been undertaken. This was identified at the last inspection, it is disappointing that action has not been taken to meet the previous requirement to have these documents available. Two written references were available for staff. For one staff a reference had not been obtained from their previous employer. The Manager said this was due to the fact that the staff had only been employed there for a short time. To ensure robust recruitment practice it is essential that references are always sort from the last employer. It is an improvement since the last inspection that the Manager now ensures a profile about agency staffs training and experience and evidence of CRB checks are obtained before new agency staff commence work in the home. Discussions with the Manager indicate a positive attitude towards training and development of the care team. Evidence was observed that new staff undertake an induction to the home. The Manager has completed a new training matrix for the staff team so that it is easily assessed what training staff have done or need to do. The matrix shows that not all staff have yet received all the training to meet tenants needs. Some mandatory training is still outstanding but it is good that many staff have recently completed nutrition and medication training. The Manager said that he was trying to arrange epilepsy training via the Primary Care Trust as this training was a previous requirement. Discussion with permanent staff shows that they are happy with the quality of the training they receive. Sampling of records and discussions with staff show that there is no program of training for casual staff. Some casual staff have not received any training for a period of three years. Given that the home is regularly using casual staff to cover shifts this situation is wholly unacceptable. Tenants are not always being supported by staff who are up to date with training in important areas such as manual handling, food hygiene, first aid and fire. Discussion with the representative of FCH indicates that this is an issue that they have recently identified and have completed an audit of the training needed for casual staff. Supervision records for three staff were sampled, these showed that the quality of supervisions is good but that the frequency was variable, this needs to improve to ensure the standard of six per year is met and to ensure staff are well supported in their job role. Manor Park Grove, 5 DS0000016800.V307396.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is working towards meeting positive outcomes for tenants and ensuring that tenants benefit from a well run home. Arrangements to ensure that the health, safety and welfare of tenants is promoted and protected are variable. EVIDENCE: Since the last inspection the Manager has been successful in applying to the CSCI for registration. Direct observations and previous inspection reports indicate that the style of management is open. The Manager has a clear sense of direction and of the improvements needed. Whilst progress towards meeting some previous requirements has been a little slow the Manager clearly wanted things to be done right with positive outcomes for tenants, rather than rushing things as a token gesture towards meeting requirements. Staff spoken with said the Manager was approachable. Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 24 A representative from FCH, the Provider visits the home monthly and writes a report of their visit as required under Regulation 26. However the reports for these visits were not available in the home. The Manager said the report file had been removed by the representative for auditing to make sure the home had copies of all previous reports. 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 last inspection that Quality Assurance is a key theme for development within FCH in 2006. The Manager has undertaken some internal audits to include medication and staff file audits. A number of health and safety documents were sampled. An examination of the home’s fire safety records indicate that routine testing of alarms is being carried out at the appropriate frequencies. Emergency lighting is now being tested monthly rather than the previous three monthly tests. Certificates were available to evidence the regular servicing of the Arjo bath, fire alarms, gas and electrical appliances. It is good that the Manager has completed a matrix showing the dates of servicing of appliances and equipment because at a glance staff can check when things are due. It has been required at the last two inspections that staff receive fire training at least six monthly to ensure they are aware of fire prevention and respond appropriately in the event of a fire occurring. Staff have now received this training. Staff test the water temperatures weekly and keep a record of these. These showed that most of the temperatures are below the safe recommended temperature of 43 degrees centigrade. It was identified at the last inspection that the fridge temperatures were quite high, discussion with the Manager indicated that staff felt it was the thermometer that was inaccurate and not a problem with the fridge. The Manager said a new thermometer was being obtained. At this inspection visit there were lots of gaps in the fridge temperature records. From the 1st May to 24th May there were no recordings at all as a note had been added saying the thermometer was broken. Three weeks is quite a long time to replace the thermometer. Action must be taken to ensure effective monitoring of the safe storage of food. Risk assessments for the premises were observed to be well overdue for review at the last inspection in January 2006 and a requirement was made for this to be done. No progress has been made towards reviewing any of the premises risk assessments. Manor Park Grove, 5 DS0000016800.V307396.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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 2 X Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 12(1) 14(1) Requirement The admission policy and procedure requires review to ensure it reflects the National Minimum Standards with regards to the admission and assessment process. Outstanding requirement. Care plans require further improvement to ensure: They are reviewed at least six monthly. Outstanding requirement from 30/10/05 and 28/02/06. Ensure actions agreed as part of tenant review meetings are completed within the agreed timescales. Medication: Ensure medication policy includes arrangements for controlled medication. Ensure action is taken to reduce the risk of medication errors occurring. The lounge and dining DS0000016800.V307396.R01.S.doc Timescale for action 30/10/06 2. YA6 14 30/10/06 3. YA6 12(1) 14 30/10/06 4. YA20 13(2) 30/09/06 5. YA24 23(2) 30/10/06 Page 27 Manor Park Grove, 5 Version 5.2 6. YA34 YA23 13(6) 19 7. YA23 YA34 13(6) 19 8. YA35 18(1)(c) 13(6) 9. 10. YA35 YA36 18(1)(c) 18(2) 11. YA39 14 12. YA39 26 room carpet need to be deep cleaned or replaced if the stains cannot be removed. Evidence of CRB checks must be available in the home for all staff. Disclosure must be available on site for 12 months. Outstanding requirement from 28/02/06. Ensure that for all prospective new staff references are sought from their previous employer. Ensure staff have received all the training they need to meet tenant needs to include: Adult Protection Manual Handling Epilepsy Diabetes Outstanding requirement from 28/02/06. The registered provider must introduce a program of training for casual staff. Ensure all staff receive supervision at least six times per year with a record maintained in the home. A formal quality assurance system must be in place that seeks the views of tenants and their representatives. Outstanding requirement from 30/04/06. Reports of the monthly visits made to the home by the representative of FCH must be available in the home. Outstanding requirement DS0000016800.V307396.R01.S.doc 30/10/06 30/09/06 30/11/06 30/11/06 30/09/06 30/11/06 30/09/06 Manor Park Grove, 5 Version 5.2 Page 28 from 28/02/06. 13. YA42 13(4) Risk assessments for the premises must be reviewed annually. Outstanding requirement from 28/02/06. Ensure the fridge temperatures are monitored on a daily basis and food is stored within safe temperatures. 30/09/06 14. YA42 13(4) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that written protocols for ‘as required’ medications that are no longer in use are not stored within the current medication file to reduce the risk of errors in administration. Communal Space: The home has a combined lounge and dining area. There is no alternative communal space for tenants to receive visitors or take part in activities or have space away from the other service users. Consideration should be given to the provision of extra space, for example a conservatory. Brought forward from previous inspections. 2. YA28 YA24 Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 29 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 Manor Park Grove, 5 DS0000016800.V307396.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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