Inspection on 11/07/07 for Manor Park Grove, 5

This inspection was carried out on 11th July 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 no outstanding requirements from the previous inspection report, but made 10 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 01/08/06

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 Key Unannounced Inspection 11th July 2007 09:20 Manor Park Grove, 5 DS0000016800.V340059.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.V340059.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.V340059.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) 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, 5 DS0000016800.V340059.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 1st August 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 Aquanova 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. Information from the Manager indicates that the standard fee is £1157.74, 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.V340059.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over eight hours, the home did not know we were coming. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for peoople 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 provisions 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 a pre inspection questionnaire (AQAA). 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 peoples care helps us understand the experiences of people who use the service. All people who live at the home were spoken to. Due to their communication needs some 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 part of the day. Discussions with staff took place and the Manager was available for part of the visit. CSCI survey forms were received from the relatives of two people who live at the home and one health professional. Their comments are included in the report. 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. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 6 Staff support people to keep in contact with their family and friends. People living in the home often go out so that they do the things they enjoy doing. People who live at the home can choose what they want to eat and are offered a healthy diet. 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. People have the input they need from health professionals to assist in meeting their healthcare needs. 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? People who live at the home have been provided with their own copy of the service users guide so they know what services the home offers. New terms and conditions documents have been produced so that people know the terms and conditions of their stay and how much it costs. Peoples care plans have been kept up to date so that staff have the information they need to meet peoples needs. Opportunities for activities for people to participate in have improved as activities are now better planned with each person having their own schedule. Some areas of the home have been repainted so that the rooms look nice. All staff have had training in epilepsy so that they will know how to keep people safe if they have a seizure. Staff have regular supervision and support so that they know how to meet the needs of the people living there. The fridge temperatures are kept at a safe level to make sure that food is stored safely and people are not at risk of food poisoning. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Manor Park Grove, 5 DS0000016800.V340059.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.V340059.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. No new people had been to admitted to the home for sometime. Therefore, the standard relating to assessment was not fully assessed at this inspection. 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 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. One Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 10 person who lived at the home said that staff had explained the service user guide and contract to her. Manor Park Grove, 5 DS0000016800.V340059.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 good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so they know how to support the people living in the home. Risk assessments ensure that risks to people living in the home are managed in a safe and responsible manner. People are consulted on how they wish care and support to be provided. EVIDENCE: The care provided to three people who live at the home was case tracked. This included sampling of their care plans and risk assessments. 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. This has now been done. 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. Care plans sampled had some good information about individual’s diverse needs to include cultural needs. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 12 Evidence was available to show that review meetings are held on a regular basis with people who live at the home. Each person’s records included up to date individual risk assessments. These covered areas such as finances, inappropriate behaviour, night support, choking, falls, sunburn, fire, manual handling and friendships with neighbours. Some good work had also been done on including one person 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 person could understand it. Members of staff were observed encouraging people to make choices about day-to-day matters, such as what to have for breakfast, and what they wanted to do on that day. Staff gave examples of how people had participated in choosing new décor for the shower room. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. One person has recently refused dental treatment but it is unclear if they have the capacity to make this decision and understand the implications of refusing treatment. 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, 5 DS0000016800.V340059.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, 14, 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: At the last inspection it was identified that the structure and planning of activities was sometimes on an ad hoc basis. This has now improved and people now have individual activity timetables. It is good that activities are undertaken on a 1:1 basis as well as in groups. Records and discussions with staff show that activities on offer include food shopping, library, community centre, flower arranging at college, cinema, bowling, voluntary work and church services. Support notes have been completed for some activities so that staff know what support the person needs to make the activity successful. One person said they had been on holiday this year and that they had chosen to go to Blackpool. One person supports Birmingham City Football Club, staff Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 14 said he had just purchased a new season ticket and often goes to watch matches with a friend from another home. Activities on offer are generally culturally appropriate, for example one person goes to Cherish House twice a week. Cherish House is a Chinese community centre, the person gets a Chinese meal there and meets friends from same culture. At one persons review meeting in November their family said they would like them to attend the temple on special occasions. Records show some staff thinks the person has previously enjoyed this, others think they get upset. There was no evidence to show that this had been explored further. Discussion with staff and one person who lives at the home showed that people are supported to maintain contact with their family and friends by visits, telephone calls and sending cards. People had photos of their relatives in their bedrooms. Last year a garden party was held, lots of people were invited to include people at other homes, neighbours and relatives. For one person staff had arranged for their yearly review to be held at their Mothers house due to the mobility difficulties of their Mother. Minutes of a staff meeting in June show that staff are trying to arrange for one persons friend from Kennedy House to visit for tea. One relative commented that she received a letter from her sister every month through the staff. 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. Staff said they sit with people and look at pictures to assist them in choosing the menu. They said they hope to improve this by taking photographs of meals that people will find easier to recognise. People on special diets are catered for, one person has diabetes and has their own individual menu. Manor Park Grove, 5 DS0000016800.V340059.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 usually 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: Care plans indicated the degree of assistance required for personal care, this varied form very little such as prompting to full personal support. Staff had paid attention to each persons personal care, people were wearing clothes in good condition suitable to their age and gender. Each person had an up to date assessment of how staff are to support them with moving and handling. 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. One health professional commented that the home usually seeks and acts upon medical advice. Records showed that people had regular check ups with the dentist, optician, dietician and GP where appropriate. However, as stated earlier in this report one persons refusal to have dental treatment needs further exploration. One person has diabetes, their care plan Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 16 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. One person has been assessed by the Speech and Language Therapist as having dysphagia (swallowing difficulties). Guidelines said this person needs to have a soft diet with foods cut up. A separate list of high risk foods to avoid included peas and sweetcorn but food records sampled showed that on some occasions the person had been given sweetcorn and peas. The Manager said they was okay to have these, but this was not clear from the care file. For one person staff keep a record of when they have had their bowels opened. The record had generally been regularly completed but had not been completed for the last eight days. It was not clear if the record had not been completed because staff had forgot or if the person had not opened their bowels during this time. The Manager is currently working on Health Action Plans for people. 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. 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. Since the last inspection the medication policy has been updated to include controlled medication. Staff who administer medication have been trained to do so. 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. Medication administration records were sampled and found to be in good order. Since the last inspection two medication errors have occurred. Appropriate action has been taken to prevent future occurrences. As a result of one incident a member of staff has been suspended from administering medication until an investigation has been completed. As a result of another incident the procedure for taking medication on peoples holidays has been changed so that it is checked by two staff. The home has a system of auditing medication, this is usually done monthly but has not been done since March, it was recommended this is reintroduced to ensure medication is being given correctly by staff and any errors are quickly spotted. Information was sent following the inspection to confirm that an audit had been done and that one tablet was found to be missing during the audit. Manor Park Grove, 5 DS0000016800.V340059.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 poor. This judgement has been made using available evidence including a visit to this service. Staff do not have all the knowledge and skills they require to protect people from the risk of harm in the event an allegation is made. EVIDENCE: The complaints procedure is included in the service user guide and is on display in the home. One person who lives at the home was spoken with and was aware of the complaints procedure. Two relatives said they were aware of the procedure, one said they had never had to complain the other said that any concerns are responded to. The CSCI has not received any complaints about the home in the last twelve months. The home’s complaint log detailed that a recent complaint had been made by someone who lives at the home. They alleged that staff had shouted a them ‘at the top of their voice’. As the complaint alleged misconduct by staff this should have been notified to the CSCI under the Care Home Regulations but this was not done. It is important that such allegations are notified so that the CSCI can ensure the proper action is being taken. Shouting at people can potentially be abusive behaviour and consequently the allegation should also have been notified to Social Services to discuss if an investigation under adult protection procedures was needed, again this was not done. The allegation was investigated by the Manager and although upheld there was no evidence that the matter had been dealt with formally to ensure the protection of people at the home. It is of concern that adult protection procedures had not been followed and that discussion with the Manager indicates he was reluctant to Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 18 accept that the appropriate procedures had not been followed although he did accept that the CSCI should have been notified of the incident. The majority of staff at the home have received adult protection training but it was not evident that the Manager had received any recent training. However the Manager was able to evidence that he was booked to attend training in August. One new staff who started working in the home in April had not done any basic training in adult protection procedures as it was not part of the homes induction. The Manager added this topic to the induction checklist when this was brought to his attention. 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. The financial records for one person 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. 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 needed improvement. Personal items such as TV, radio, jewellery and lamps are recorded but the inventory does not include clothing. It needs to be recognised that some clothing has cost a lot of money and so needs to be recorded so that staff can track if anything has gone missing. Recruitment procedures were not robust enough for the protection of people at the home as some references were not adequate and staff employment history was not explored fully. This puts people who live at the home at risk of having unsuitable people working with them. Discussion with the Manager indicates that he did not agree that the procedures were not robust. This is further detailed in the staffing section of this report. Manor Park Grove, 5 DS0000016800.V340059.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, 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: The home was seen to be generally well maintained, homely, comfortable, and free from odour. The lounge carpet was observed to have been deep cleaned since the last inspection so that stains were no longer visible. 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. 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 Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 20 in activities of have space away from other people. This is not ideal. The development plan for the home indicates that funding for a conservatory is to be sought. Repainting of communal areas to include the lounge, kitchen and hallways has been done since the last inspection. This makes these areas look nicer. One staff raised concern at their supervision in March that there was no blind at the kitchen window and neighbours could look straight in. The kitchen was observed to have no blind at the window. The Manager said a blind had been purchased but was not suitable. An alternative therefore needs to be considered so that the privacy of people at the home is respected. 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. One person did not want their bedroom to be seen and this was respected. The home was clean and free from offensive odours. Satisfactory hand washing facilities were observed in the bathroom, laundry and kitchen. Manor Park Grove, 5 DS0000016800.V340059.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 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). To ensure people are supported by a qualified staff team at least 50 of staff need to achieve an NVQ in care. The home currently has three staff vacancies. The Manager said that these posts had just been recruited to at recent interviews. The rota showed that staffing levels had been maintained at two to three staff during the day by staff working extra hours or by using casual staff. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 22 The recruitment files of two staff were sampled. These did not evidence that a robust procedure had been followed. Criminal Record Bureau checks had been obtained for both staff. The application form for one member of staff only recorded their work history back to 2002, 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 2002. Discussion with the Manager indicates that he did not think it was important to further explore a candidates work history. One member of staff only had one satisfactory written reference. The Manager said he thought that a written letter from the benefits agency confirming the person had received benefits would count as a reference. However this did not provide any information in relation to the persons suitability to work with vulnerable people. 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 diabetes and dysphasia (eating / swallowing problems) despite people at the home having these needs. Most of the staff have done training in medication, fire, first aid and adult protection. Manual handling training is booked in August for staff who have not done it before but refresher training is needed for other staff. One new member of staff was spoken with who was very complimentary about the LDAF training she had done. An Improvement plan dated 29th September 2006 from the last key inspection stated that an audit of casual staff training was underway and this would lead to a planned training schedule. The completion date was given as December 2006. 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. The Assistant Team Leader said that fire and manual handling training was to be offered to casual staff via video at the end of the month. Minutes show that staff meetings are held monthly. Records sampled and discussions with staff show that staff had received regular formal, recorded supervision sessions. This ensures staff get the support they need. Manor Park Grove, 5 DS0000016800.V340059.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, 39 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In some instances the home has not been effectively managed for the protection of the people that live the. 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. Evidence from this inspection shows that whilst some outcomes for people have improved there are other areas that were poor. Discussion with the Manager indicates that he was reluctant to accept that issues around adult protection and staff recruitment had been poorly managed. Discussion with the Manager following the inspection indicates that he has not kept himself fully up Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 24 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 home does have policies and procedures in place for quality assurance but the tools recorded in the policy are not all put into practice. However some progress has been made with some new audits introduced. This includes an audit completed by night staff and an infection control audit. A monthly audit of activities has also been introduced but this had not been completed since April. A service development plan has been completed. This recorded some key objectives for the home to include minimum community activity levels, establish local quality audits and apply for funding for a conservatory. A representative from FCH, the Provider visits the home and writes a report of their visit as required under Regulation 26. Reports available in the home showed these visits are generally done 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. One person who lives at the home had also attended recent fire training and said she had passed the test. It is good that a simple version of the fire procedure in pictorial form is on display to help people know what to do if a fire occurs. 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. 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. Some sauces in the fridge were not dated on opening such as cranbury sauce, chilli bean and peanut butter. A jar of pickle that was open had the use by date of December 2006, this puts people at risk of food poisoning. 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. Accident records showed that one person had a fall when they were supported by a staff who had not been trained in manual handling, the record said the staff needed to be nominated for training. It is not good practice that this staff continued to undertake manual handling tasks without being trained as another person slipped and fell whilst being supported by the same staff from her wheelchair. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 25 Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 26 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 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 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 27 Yes, number 8 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 YA19 Regulation 12(1) Requirement Clear guidance is needed to ensure the dysphagia needs of people are met and they are not given foods that could pose a risk of choking. Where assessed as needed bowel monitoring records need to be completed so that the risk of constipation is properly managed. Any allegation of misconduct by staff must be notified to the CSCI so they ensure the appropriate action to protect people is being taken. Allegations of possibly abusive practice must be notified to Social Services under adult protection procedures to ensure the appropriate action to protect people is being taken. Ensure that all new staff receive training in adult protection shortly after commencing work in the home to ensure staff have the knowledge they need to protect people from abuse. Repairs and redecoration are DS0000016800.V340059.R01.S.doc Timescale for action 30/07/07 2 YA19 12(1) 30/08/07 3 YA23 37 15/07/07 4 YA23 13(6) 15/07/07 5 YA23 13(6) 30/08/07 6 YA24 23(2) 30/09/07 Page 28 Manor Park Grove, 5 Version 5.2 required in the shower room to ensure the home remains a nice place for people to live. 7 YA34 19 Staff recruitment procedures must be robust to include obtaining two satisfactory references to ensure people who live at the home do not have unsuitable staff working with them. Ensure staff have received all the training they need to meet peoples needs to include: Dysphagia Diabetes Outstanding requirement. All food in the fridge must be discarded by its use by date. Opened foods in the fridge must be date labelled and discarded within the timescale given by the manufacturer to ensure people are not put at risk of food poisoning. All staff who undertake 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. 30/07/07 8 YA35 18(1)(c) 30/09/07 9 YA42 13(4)(c) 30/07/07 10 YA42 13(4)(c) 30/08/07 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 DS0000016800.V340059.R01.S.doc Version 5.2 Page 29 Manor Park Grove, 5 2 3 4 5 YA7 YA12 YA20 YA23 6 YA23 7 8 YA24 YA28 9 10 11 YA35 YA34 YA37 12 YA39 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. Assessment is needed to see if one person at the home would benefit from attending the temple on special occasions. The medication audits should be completed monthly in line with the homes own procedures to ensure medication is being correctly given. 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 to include clothes 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. A new blind should be fitted in the kitchen so that neighbours cannot see in and people’s privacy is respected. 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. 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. Quality audits need to be completed within the homes own set timescales to ensure the home is being run for the benefit of the people who live there and their views are considered. Manor Park Grove, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham West Midlands 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, 5 DS0000016800.V340059.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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