Inspection on 28/11/07 for Manor Park Grove, 5

This inspection was carried out on 28th November 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 3 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 11/07/07

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 DRAFT Key Unannounced Inspection 28th November 2007 10:00 Manor Park Grove, 5 DS0000016800.V355834.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.V355834.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.V355834.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.V355834.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 11th July 2007 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 service user guide indicates that the standard fee is £1157.74, but that fees are negotiated on an individual basis dependent on needs. The fee information included in this report applied at the time of the inspection and the reader may wish to obtain more up to date information from the care service. Copies of reports from the CSCI are available at the home, on request. Manor Park Grove, 5 DS0000016800.V355834.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 seven hours, the home did not know we were coming. This was the homes 2nd 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 people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service 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). Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking 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 the majority of the visit. CSCI survey forms were received from two health professional. Their views 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. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 6 Each person living in the home has a care plan so that staff know how to support them to meet their needs and goals. Peoples care plans have been kept up to date so that staff have the information they need to meet peoples needs. Staff are very good at supporting 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. What has improved since the last inspection? One person’s capacity to refuse medical treatment has been assessed and action taken in the person’s best interests. Medication audits are being completed regularly so that any errors that have occurred are quickly identified and procedures put in place to reduce the risk of them happening again. Incidents of possible abuse have been dealt with under adult protection procedures to ensure people who live at the home are properly protected. The shower room has been refurbished so that it is a safe, homely and comfortable place for the people living there to spend time in. Staff have received more training so that they better knowledge and skills to meet the needs of the people at the home. Systems have been put in place to make sure reserve staff have opportunities to receive the training they need. Recruitment systems for new staff have improved so that people are not put at risk by having unsuitable people working with them. The Manager of the home has updated himself with areas of current good practice so that he has the knowledge he needs to ensure good outcomes for people at the home. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 7 Quality audits need have been completed within the homes own set timescales to ensure the home is being run for the benefit of the people who live there. 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.V355834.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.V355834.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 and 2 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 were up to date and included all the relevant and required information. The service user guide was in an easy read format that included pictures. This gives 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. Discussion with the Manager indicates that any new people would be fully assessed before they moved into the home. The Area Manager for the home said that the admission policy had recently been reviewed but that the new one was still in a draft format. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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 two people who live at the home was case tracked. This included sampling of their care plans and risk assessments. As at the last key inspection in July 2007 care plans were seen to be up to date. 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. Evidence was available to show that review meetings are held with people who live at the home. Where appropriate, relatives of people who live at the home are invited to attend the review. For some people Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 11 the Manager had identified that reviews were now overdue, plans detailed that arrangements for reviews were to be made. Each person’s records included individual risk assessments. These stated how staff are to support the person to minimise the risks in areas such as finances, night time support, choking, falls, sunburn, fire evacuation and manual handling. All risk assessments were detailed, had been regularly reviewed and updated where the person’s needs had changed. 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. One person was observed to answer the home’s telephone and also collect the post when it arrived. Some people who live at the home have difficulties in verbally communicating some of their choices and preferences. Since the last key inspection a member of staff has sought their preferences to include food and clothing by completing a collage of pictures they have chosen reflecting their preferences. At the last inspection it was identified that one person had refused dental treatment but it had not been clear if their capacity to understand the implications of refusing treatment had been assessed. This person said that since the inspection she had a meeting with people such as her community nurse, sister and the Manager and it had been agreed that her decision not to go to the dentist would be respected. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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: 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, community centre, flower arranging at college, cinema, bowling, crafts, pampering sessions 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. During the inspection one person went out with staff to their flower arranging class, another person had gone to the day centre. The remaining two people did not do activities in the morning as they were attending health checks. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 13 One person supports Birmingham City Football Club, staff said he had purchased a new season ticket and often goes to watch matches with a friend, supported by a member of staff. Records showed that people are supported to attend celebration events such as Bonfire Night. One staff said that arrangements were being made for people who wanted it to attend a pantomime at Christmas. 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 the same culture. 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. It is good that Christmas card lists are kept for people so that they can send cards to all their friends at the community centre they attend. One person has recently been supported by staff to make some cards to send to relatives. 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 last yearly review to be held at their Mothers house due to the mobility difficulties of their Mother. Food provided and menus are appropriate to and reflect the cultural background of the individuals who live in the home. Menus showed that meals on offer are varied and nutritious. Where people have special dietary needs due to having diabetes or dysphagia menus were seen to meet their needs. Satisfactory food stocks were available and these included fresh fruit and vegetables. Most of the food is home made, for example records show that one person had the chance to help staff in making a Christmas pudding. Daily records and discussion with one person who lives at the home shows that people are involved in doing the food shopping for the home. This includes shopping in places such as the Chinese centre in Birmingham so that culturally appropriate foods are available. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Some improvement is needed to ensure people’s health care needs are always recognised and responded to ensuring that their health is promoted. Personal support is not always given in a way that meets people assessed needs. People who live at the home usually receive their medication safely and as prescribed by the GP. 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. Records showed that people are regularly supported by staff to go to the hairdressers or barber. Each person had an up to date assessment of how staff are to support them with moving and handling. However for one person staff were observed to initially support them in a way that did not comply with their assessment. Their assessment completed by a physiotherapist said they needed to be supported when walking by using a ‘handling belt’. Staff were seen not to use this, but later used it when reminded to do so by the Manager. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 15 Two surveys have been received by the Commission from health care professionals. Both said that people’s healthcare needs were usually met by the home. At the last inspection the Manager was working on Health Action Plans for people. These have now been completed. 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. 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. Food records sampled at the last inspection showed that on some occasions the person had been given high risk foods. Since then the majority of staff have attended dysphagia training. Records show this person now only has foods that do not pose a high risk. Where one staff did not follow the guidelines action has been taken to ensure they follow the guidelines in future. It was identified at the last inspection that where people needed monitoring due to the risk of constipation this was not always being done. The records for one person were sampled at this inspection and found to be completed daily. Records sampled show that people’s weight is regularly monitored, on the day of the inspection visit staff were taking two people to their regular appointment at the weight clinic. The general healthcare provided to two people was looked at. For one person there was evidence that they attended regular health checks to include the optician, dentist and GP. For another person the home needed to be more proactive in ensuring they attended regular health checks. Their review minutes of April identified they needed to attend an annual check up at the dentist and opticians. Their health action plan identified their last known dental appointment as August 2006 where some gum disease was observed by the dentist. It was an agreed action from the health plan that appointments needed to be made for this person regarding the dentist, optician, well mans clinic and to seek reassessment regarding the number of falls they had. The plan stated this would be done by the end of November, the Manager said these were still to be booked. It is disappointing that it appears to be over fifteen months since the person attended the dentist, given that gum issue was identified by the dentist an new appointment is needed as soon as possible to make sure the person is not in discomfort. 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. Staff who administer medication have been trained to do so. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 16 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 key inspection a photo of each person has been added to front of their medication basket so that staff can quickly identify where each person’s medication is stored. Some minor medication errors have recently occurred, the home informed the Commission about this. Appropriate action has been taken by the home to prevent future occurrences. This has included a change to procedures and an increase in medication audits. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place for investigating concerns and complaints and staff are being trained to report suspicions of abuse so that people are protected form harm. EVIDENCE: The complaints procedure is included in the service user guide and is on display in the home. At the key inspection in July 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 has a log book for complaints received, this showed that the home had not received any direct complaints since the last key inspection. Some concerns regarding protecting people who live at the home from the risk of abuse were identified at the last inspection and work has been now been done by the home to improve things. The Manager has attended refresher training in adult protection and has reinforced adult protection procedures to staff during a staff meeting. Discussion during the inspection with one member of staff showed they were aware of what to do if they suspected abuse had occurred. Since the last inspection there have been two allegations made about staff who work at the home. In both instances the Commission were informed of Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 18 the allegations. One was reported to social services as an adult protection matter. Action taken by the home was in line with adult protection procedures. One person who lives at the home is assessed as bruising easily, they also have a history of scratching themselves. Care plans and risk assessments have been completed and record where bruises usually occur, guidance is given within the plan of areas of the body where bruises would cause concern. Since the last inspection two incidents of bruises have been reported to the Commission and Social Services and the home has followed adult protection procedures. For one incident the home had not received a response from Social Services regarding information sent to them by the home, the Manager was advised to follow this up with Social Services. The majority of staff have now 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 recruitment procedures for new staff have been reviewed to make sure that people are not put at risk of having unsuitable staff working with them, this is further detailed in the staffing section of this report. 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 recording of people’s personal belongings 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. The Manager said that the home did intend to do this. Manor Park Grove, 5 DS0000016800.V355834.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, 25, 26, 27, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is maintained in a comfortable, clean and tidy condition so that people benefit from a homely environment. EVIDENCE: The home was seen to be generally well maintained, homely, comfortable, clean and free from odour. Satisfactory hand washing facilities were observed in the bathroom, laundry and kitchen. Since the last inspection the shower room has been refurbished as previously water has been seeping through the join in the flooring and tiling. This water seepage had damaged some areas of paintwork in the hallway. The Manager said that the paintwork and plaster would now be repaired following the refurbishment of the shower room. The home has a combined lounge/dining area, which is the only shared space available. Some staining to the dining room carpet has occurred since the last inspection, the Manager said that quotes were being obtained to provide a new Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 20 floor covering to this area. There is no communal space for people to receive visitors, take part 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. The Manager said that as yet, no funding is available. As at the last inspection the kitchen was observed to have no blind at the window. One staff raised concern at their supervision in March that there was no blind at the kitchen window and neighbours could look straight in. Bedrooms seen were well decorated according to individual’s tastes, interests, age and gender. They contained many personal possessions. One person did not want their bedroom to be seen and this was respected. Manor Park Grove, 5 DS0000016800.V355834.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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a generally well trained staff team that can support them to meet their individual needs and achieve their goals. People are now 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. Staff have the opportunity to undertake the Learning Disability Award Framework (LDAF). The Manager said that since the last key inspection one more staff had completed an NVQ so that now the home have 50 of staff with an NVQ. The home currently has five staff vacancies. The Manager said that two potential new staff 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 reserve (casual) or agency staff. Staff recruitment records were sampled at the last key inspection, Criminal Record Bureau (CRB) checks were observed to have been obtained in the staff Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 22 files sampled. However some poor practice was identified in regards to the type of references sought by the home and potential staff’s full work history not being sought. Discussion with the Manager and Area Manager indicates that recruitment procedures have now been improved across the organisation. No new staff have started work at the home since the last inspection but some recruitment information for potential new staff was available. The Manager has designed a new form to clarify candidates work history to include gaps in employment at interview stage, the form was observed to have been used for one recently interviewed potential staff. Evidence was also available to show that the human resources department of the organisation has updated the application form regarding people’s work history. Where agency staff have been used the home has obtained profiles of the agency staff used to evidence they have CRB checks, and have the right experience and training to meet peoples needs. At the last inspection it was identified that staff had not had training in meeting the needs of people with diabetes and dysphagia. Discussion with staff and observation of training records shows that the majority of staff have now had this training. As stated earlier in this report most staff have also recently attended training (briefing session via Birmingham City Council) on the Mental Capacity Act. Records show that most staff have been trained in adult protection, food hygiene, 1st aid, medication, epilepsy and health and safety. It was identified at the last inspection that some staff needed refresher training in manual handling, one staff spoken with confirmed she had recently been to do this training, the training schedule showed that two staff were scheduled to attend this after Christmas. Some staff had not had manual handling training in the last twelve months and were not scheduled to attend refresher training. It is considered good practice for staff to have refresher training every twelve months. The Manager said that training was being arranged on the use of a hoist the home had recently obtained, he said staff were not using this until they had the training. The home uses reserve staff to cover staffing shortages. At the last two inspections it was identified that despite some reserve staff working regularly at the home there were no training plans in place for them. This has now been resolved and an audit has been completed of what training reserve staff have previously completed. From this, a training schedule has been developed so that reserve staff will have opportunities to attend the training they need. Manor Park Grove, 5 DS0000016800.V355834.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 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 have improved to ensure that the people living there generally benefit from a well run 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. At the last inspection some issues that needed improvement with regards to how the home was being managed were identified. The Manager has acted on the improvements needed. Since the last inspection he has attended training on adult protection and the mental capacity act and is scheduled to attend fire and manual handling training. Issues regarding staff practice, adult protection and staff recruitment have been generally well Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 24 managed since the last inspection in July. The Manager has also put in place a new rota system that clearly shows the hours he is working, this avoids confusion as the Manager is also registered with the Commission to manage another small care home on the same road. 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 a wide range of quality audits are completed to include infection control, fire, night time audits and medication. What needs to improve is how the home seeks the views of people who live there and their relatives / involved professionals. 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 done monthly. 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. Fire records showed that a risk assessment is in place so that the risks of there being a fire are minimised, however the risk assessment should be reviewed as it is over twelve months old. An engineer regularly services the fire equipment to ensure it is well maintained. Previously staff have test the fire alarms on a weekly basis but records show that since July there have been many times when the test has been missed. Discussion with the Manager shows he was aware of this, however action needs to be taken to make sure the tests are done. The fire drill record showed the last drill happened in February so another one should have been arranged by August but this was not done. The temperature of the water is regularly monitored to ensure it will not pose a risk of scalding to people. Records showed that the temperatures to the hot water supply are often 36C, staff need to make sure people are happy with this temperature and it is not too cool for them. 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. There had been gaps in the monitoring in October but this has been resolved by the Manager. 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. As stated earlier in this report one person was observed to be supported by staff when walking without the handling belt being used. However the home has made some improvements and more training has been scheduled for some staff, but not all. General risk assessments were seen to be in place for the premises, but as with the fire risk assessment these need to be reviewed to make sure all the information is up to date. Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 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 3 25 3 26 3 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 2 X Manor Park Grove, 5 DS0000016800.V355834.R01.S.doc Version 5.2 Page 26 No 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 Ensure people are supported to attend general health checks to include the dentist so that they are not put at risk of discomfort, pain or poor health. Timescale for action 15/01/08 2 YA42 13(4) Regular testing of the fire alarms 15/01/08 needs to be carried out to ensure the alarms are working correctly and people will be alerted should a fire occur. Ensure that staff undertake moving and handling tasks with people who live in the home in a safe manner, using aids or equipment that are assessed as needed to prevent the risk of injury or bruising to the person. 15/01/08 3 YA42 13(4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000016800.V355834.R01.S.doc Version 5.2 Page 27 Manor Park Grove, 5 1 Standard YA12 Assessment is needed to see if one person at the home would benefit from attending the temple on special occasions. (Recommendation from last inspection) Ensure people are provided with personal support from staff in line with their assessed needs to ensure care is delivered in the way individuals require and their health, well being and safety is promoted. 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. (Recommendation from last inspection) A new blind should be fitted in the kitchen so that neighbours cannot see in and people’s privacy is respected. (Recommendation from last inspection) 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. (Recommendation from last inspection) Quality assurance systems need further development to include the views of people who live at the home, their relatives / advocates and involved care professionals and include the information in the homes annual development plan. The fire risk assessment needs to be reviewed to ensure the information is still current and fire precautions are satisfactory. The frequency of the fire drill should be increased to make sure that staff who work at the home know what to do in the event of a fire occurring to protect people living at the home. The general risk assessments for the home need to be reviewed to make sure the information is up to date and people are protected from unessacary risks. DS0000016800.V355834.R01.S.doc Version 5.2 Page 28 2 YA18 3 YA23 4 YA24 5 YA28 6 YA39 7 YA42 8 YA42 9 YA42 Manor Park Grove, 5 10 YA42 All staff who undertake manual handling (to include casual staff) should have manual handling training every twelve months so that people who live at the home and staff are not put at risk of injury through poor manual handling practices. Manor Park Grove, 5 DS0000016800.V355834.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: 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.V355834.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. 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