Inspection on 16/01/06 for Mary Street

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mary Street 10/08/06

Mary Street 22/08/05

Mary Street 10/02/05

Mary Street 05/08/04

Mary Street 21/01/04

Mary Street 19/08/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mary Street 179 Mary Street Balsall Heath Birmingham West Midlands B12 9RN Lead Inspector Monica Heaselgrave Unannounced Inspection 16th January 2006 09:30 X10015.doc Version 1.40 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 Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 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 Older People. 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. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mary Street Address 179 Mary Street Balsall Heath Birmingham West Midlands B12 9RN 0121 446 5719 0121 446 5719 valp@fch.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) FCH Housing & Care Mrs Valerie Paragon Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (1) of places Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 21 service users requiring care by reason of old age (over 65). This number may include the one existing service user as at 2003, who requires care by reason of physical disability. 22nd August 2005 Date of last inspection Brief Description of the Service: FCH Housing and Care own and manage 179 Mary St, which is registered to provide care and support to 20 older people and one younger adult with a physical disability. It currently offers this service to people from the AfricanCaribbean community. The home is situated in a residential area and is close to local shops, pubs, medical centre and places of worship. It is well served by public transport. Facilities briefly include 21 individual flats, each with its own lounge, bedroom, bathroom and kitchen. Each flat has a buzzer facility to summon staff for assistance. Service users have their own lockable front door. Service users can decorate and furnish their flats to individual taste. FCH Housing and Care are responsible for the maintenance and repair of the flats and the rest of the building, which consists of a communal lounge, dining room, office, staff rooms and laundry. FCH Housing and Care also maintain the grounds. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 3 hours. The Inspector looked around the building, and inspected a number of records to include care plans, risk assessments, daily notes, fire safety records, accident book complaints and compliments book and staff rotas. Records pertaining to Health and Safety were also inspected, these including gas safety, electrical appliances, water temperatures, infection control, safe storage of hazardous substances, food hygiene and manual handling assessments. The medication procedures and records were viewed, and the storage and stock inspected. Staff files were sampled, and training records viewed. The inspector had the pleasure of meeting with the assistant manager, two care staff and eight service users. The head of care from FCH Housing and Care also contributed to the inspection process. The Inspector observed some aspects of the daily care routine. As noted on previous inspections, the staff were informative, records well organised tidy and easy to access. This is the second of two inspection visits this year. Readers are advised to read both reports in conjunction in order to get a fuller picture of the service. What the service does well: Mary Street has continued to provide a consistently good, personalised service to its service users. Service users are predominantly from the African-Caribbean culture. They are actively encouraged to contribute to the way in which they want their care delivered. This commences at the point of referral and assessment, during which time the service user and their family are actively involved in stating their needs and choices. This has ensured good standards of care, which encourage a high level of choice and independence in some aspects of the service users life. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 6 The arrangements for the management of service users medication are good, ensuring their health and wellbeing. Some are supported to manage this independently in a safe and controlled manner. The service users who contributed to the inspection process spoke highly of the manager and her care staff team. Mary Street continues to provide a caring and supportive residential experience. What has improved since the last inspection? 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. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5, 6 Prospective service users have an informed choice as to whether the home is suited to them. Some have taken the opportunity to visit and assess for themselves whether the facilities are suited to their needs. EVIDENCE: Standards 1, 2, 3 and 4 were assessed and met at the previous inspection in August 2005. Prospective service users and their family or representative do have the opportunity to visit and decide if the facilities are suited to their needs. Service users files were sampled and contained a referral form, which had comprehensive detail on all aspects of the individuals, care needs. Prospective service users are also given the opportunity for staff to meet them in their own home, during which the assessment information is further explored. This enables staff to have a fuller picture of the individuals needs which can be developed into a care plan tailored to meet their needs in a manner suited to them. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 9 Discussion with service users confirmed that some had the opportunity to visit prior to making the decision to move in. One gentleman stated, ”I visited before I moved in and it is much better than I expected. At first I didn’t used to come into the communal lounge but I do now. Some don’t like to talk, each to their own.” Another service user stated that he had met with the cook who had discussed with him his likes and dislikes. The nutritional needs of service users both from a health and cultural point of view are well explored and planned carefully. Meals may be cooked differently depending on whether someone originates from Trinidad, Tobago, Barbados, Sierra Leone or Africa. Specialist therapeutic diets are evident for those who need to maintain nutrition or appetite. This included one for someone who suffers with anorexia. One gentleman said, ”I liked the place when I saw it, and now I’m here I like it because I have my own flat and can please myself. I like a drink of Guinness with milk in it, and I like to get up at night and have a snack, they (staff) know this so I can please myself without upsetting anyone.” It is positive to see that a great deal of effort goes into exploring individual needs and preferences, which go a long way to making service users feel comfortable. Mary Street does not provide intermediate care. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The arrangements for the management of medication are good, and include safe systems for supporting service users to manage their own medication where able and willing to do so. EVIDENCE: At the previous inspection standards 7, 8, 10 and 11 were assessed. Three of these were met. The manager has since that time met the requirement of undertaking a nursing assessment for one individual. At this inspection the arrangements for the care and monitoring of the service users needs is satisfactory. Medication management was good. Records are kept of all medicines received and administered by the staff. Risk assessments were in place to enable service users to self-administer medication safely. The storage of medication was secure, and a record of disposed medicines was kept. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 11 Staff who administer medication have received accredited training, which enables them to administer safely. Medication records were well maintained. A separate cabinet is available for storage of controlled drugs; currently these are not in use. The manager has sought advice from the pharmacist regarding the management of medicines, and the most recent pharmacist report was positive. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards fully assessed on this inspection. EVIDENCE: Standards 12, 13, 14, and 15 were assessed and met at the previous inspection. At this inspection a risk assessment for choking had been appropriately and discreetly displayed to alert all staff to this possibility. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Complaints are handled properly providing service users with confidence that their concerns are listened to and acted upon. EVIDENCE: At the previous inspection these standards were assessed, and two were met. One required minor improvement, which at this inspection, had been addressed. A new complaint and compliment log has been introduced which now separates complaints information from other statistical information. This standard is now met. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 Service users live in safe and comfortable surroundings. Staff are vigilant and consistent in maintaining a positive environment for service users. EVIDENCE: All of these standards were assessed and met at the previous inspection, except for standard 25, which was assessed at this inspection. Each service user has their own self contained flat, with bedroom, lounge and en-suite facilities. Service users stated that they are very happy with their accommodation. The heating in the flats can be is controlled independently by service users. Those flats seen had domestic type lighting and table lamps. Hot water temperatures are tested and recorded to ensure service users are not exposed to the risk of scolding. A prototype for radiator covers has been commissioned to ensure low temperature surfaces. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 15 Heating and ventilation in both the flats and communal areas suited service users’ needs. There is emergency lighting throughout which meets with fire safety and health and safety requirements. The inspector was informed that the most recent Legionella certificate would be forwarded to the Commission to confirm that the water supply has been tested and is clear. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Staffing levels are appropriate to the current needs of service users. Staff continue to update their competencies and skills, which equips them to meet the assessed needs of the service users. EVIDENCE: Minimum staffing levels are being maintained throughout the waking day. This is in addition to management support and ancillary staff. There are currently 70.25 hours vacant. There had been a good response to the recent recruitment drive. In the interim, agency and reserve staff has been utilised. Rotas sampled confirmed appropriate staff numbers are on duty. Several files indicated that staff had also undertaken NVQ level 2 training, but it was not possible to establish if the required 50 target of the staff team had been met. The head of care from FCH Housing and Care agreed to send a breakdown of the NVQ achievement. Staff files show that all staff has an induction and core training to include, food hygiene, manual handling fire safety, and health and safety. Some have received training in dementia, diabetes, and patient handling all of which are specific to the work staff undertake. Accredited training in medicine awareness has also been undertaken. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 17 Staff spoken to had the required foundation level training, and a good understanding of how to meet the needs of service users in their care. Currently the managers are working on ensuring that the training provided, follows the skills for care targets, specifically that training is undertaken within the specified time periods. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 37, 38 There are good systems in place to ensure that the administration of service users money is safeguarded. There is an open and transparent system which sees service users having access to their own records, enabling them to know what is recorded about them and what to expect from staff. The health safety and welfare of service users is protected. EVIDENCE: Standards 31, 32, 33 and 36 were assessed and met at the last inspection. An Insurance Certificate is displayed showing there is cover, loss or damage. There is a business plan, which is reviewed annually. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 19 Service users financial interests are safeguarded; service users control their own money except where they may lack capacity. Records of all service users personal allowances were sampled and demonstrated that all transactions are recorded and receipted. Where the bankbooks or pension books are looked after for service users, secure facilities were seen to be available. Service users commented that they have assistance to budget their money, make out shopping lists and can have support to go to the post office, bank or shops, or have staff undertake this for them. They were happy with these arrangements. The health safety and welfare of service users continues to be well managed. The manager has continued to ensure that all equipment and heating systems are maintained properly, certificates for these were seen. Risk assessments for moving and handling service users, risk of choking, risk of falls and fire risk assessments have been incorporated into service user care plans; these further promote the safety and welfare of service users. The arrangements for infection control, safe storage of hazardous substances and maintenance of gas and electric appliances were good. A new fire screen had recently been fitted in the hatchway between the kitchen and dining room on the recommendation of the fire officer. The management of incidents and accidents meets with requirements. Safe working practices continue to be maintained, which ensure the health and wellbeing of service users and staff is promoted. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X 3 X STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 3 X 3 3 Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP28 Regulation 18(1)(a) Requirement The Registered Person should demonstrate that 50 trained members of care staff NVQ level 2 is achieved. The Registered person should ensure that the staff training programme meets with the Skills for Care targets specifically the time scales. Timescale for action 31/03/06 2 OP30 18(1)(a) 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP25 Good Practice Recommendations A copy of the most recent Legionella certificate should be forwarded to the Commission. Confirmation that radiators are covered or have guaranteed low temperature surfaces should be sent to the Commission. Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mary Street DS0000017013.V276359.R01.S.doc Version 5.1 Page 23 - 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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