Inspection on 22/08/05 for Mercian House

This inspection was carried out on 22nd August 2005.

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

Mercian House 24/02/06

Mercian House 07/03/05

Mercian House 16/12/04

Mercian House 24/03/04

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 30/01/2009.

CARE HOME ADULTS 18-65 Bamville Road, 1 1 Bamville Road Ward End Birmingham B8 2TJ Lead Inspector Susan Scully Announced 22 August 2005 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 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 Stationary 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. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bamville Road, 1 Address 1 Bamville Road Ward End Birmingham B8 2TJ 0121 326 0491 0121 688 5797 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Janice Hutton Janice Hutton Care Home 3 Category(ies) of Learning Disability - Over 65 registration, with number of places Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 March 2005 Brief Description of the Service: Bamville Road is a 100 year old, domestic style end of terrace property situated in a residential area and in close proximity to a school within the Ward End vicinity of Birmingham. The home offers accommodation to three people with learning difficulties who have lived at the home for a significant number of years. The facilities include lounge, dining room, kitchen, laundry, rear garden, one ground floor and two first floor bedrooms and a small office. The bedrooms vary in size and one was noted to be quite small. The registered manager has arranged a sheltered area with seating within the rear garden for the service user who smokes; the facility permits staff observation from the kitchen window. There are no off road parking facilities. The first floor of the home was extended approximately 5 years ago with a view to increasing the accommodation to six service users; to date this has not been progressed although an application was submitted two years ago as it does not meet the existing standard and the application is unresolved. The home is well situated for local amenities, being close to bus and train routes and Ward End shopping facilities. Care is offered with normal lifestyle principals and service users are allowed to go out unaccompanied. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited the home over a one-day period. The methodology used in the production of this report consisted of, speaking to residents and management. Sampling of records such as Care Plans, daily records and Health and Safety documentation. The findings are documented in the main body of the report. A tour of the building was completed that included residents bedrooms, and facilities used by the resident. This was to ensure the residents were comfortable and the building was fit for its stated purpose. The inspectors would like to thank residents and management for their contribution during the visit. What the service does well: What has improved since the last inspection? What they could do better: Some health and safety issues were identified during the visit. Improvements are required in recording of risk assessment to include specific Health Care need. Care plans require additional information in some areas. It must be noted significant improvements have been made in this area. Window restrictor must be adjusted to meet the recommended requirements. Fire Safety door must close into the rebate to prevent the spread of fire. Risk assessments must be completed for residents who self-administer medication. The manager must complete a robust recruitment procedure for all new employees. All resident must have a contract of terms and conditions of residency signed by the resident where possible. A robust recording system is required for residents monies held by the manager. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 6 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. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 5 An initial assessment takes place before admission with detailed information to enable the resident and manager to make a decision. All residents must have a contract of terms and condition. EVIDENCE: The residents have lived at Bamville Road for a number of years. An initial assessment was completed before admission. Full consultation was completed with the resident, social worker and the manager. The manager said “ all resident were offered a trail period and short stay if they wished’’. A care plan was produced for the individual that has subsequently been amended to identify the increasing age and ill health. One resident file contained a blank contract of residency and this must be completed. All contacts must be signed and dated by the resident where possible. If the resident cannot sign the contract an advocate, relative, or appointee must be involved. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 Comprehensive care plans give details of the assessed needs of residents and give support to enable residents to reach their potential and aspiration. Reviews must take place on a regular basis. Not all risk assessments give detailed information of how the risk is managed. EVIDENCE: All three residents have an individual care plan detailing their assessed needs. Information includes, social and spiritual needs, any special diet, health care previous conditions and present. Daily living activities, medical records, medical support, psychiatric consultation, GP visits, hospital appointments, and any relevant information pertaining to the residents health. One resident care plan indicated he was an asthmatic, a review had not been held. The care plans give a comprehensive view of the resident health and care, however the manager must review the care plans at least 6 monthly in particularly for residents who have a medical condition. Risk assessments are completed for resident’s aliments, health and general wellbeing. Other risk assessments include: Food, Premises, Medication and Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 10 Travel. One risk assessment requires information regarding the management of one resident who may inflict self-harm, and exhibits challenging behaviour. Details are required that include how this is monitored and reviewed. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 16, 17 Residents make their own choices in what activities they want to participate. Meetings are held regular to discuss issues surrounding the running of the home. Meals provided are chosen by the resident with support from management to maintain a health balanced diet. EVIDENCE: Each resident has a daily activity plan giving details of activities the resident participate in. These include visit to shops, day centre, outings, such as going to the pictures, lunch out in Wolverhampton town centre, shopping in Birmingham, and holidays. One resident said “ we are all going to Jamaica again and I really enjoy the Holiday last time it was lovely’’. One resident enjoys football, and watches all the matches. This is adopted as part of his daily living plan. The manager said “ this is one of his needs so we make sure he is home for the match’’. “He has a television in his room where he likes to enjoy the football and other programmes’’. The Manager said “Each day residents choose what they want to eat’’. “ There is a weekly menu but its not really used’’. Recorded in daily records is what each resident has chosen each day to eat. One resident said “ I enjoy my Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 12 meals they are what I like no one plans their meal a week in advance’’. The Manager said “ since the menus were introduced this resident felt he had to chose what was on the menu, so it has been explained to him this is not the case, the menus are a guide’’. The manager had recorded the meetings held with this resident that gave details of the reassurance given. Regular meetings are held to discuss the running of the home and any improvements that would improve the quality of life for the residents. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Residents are fully consulted in how they wish their care to be provided. Health care needs are identified and the appropriate action taken. Records pertaining to medication require additional information and a risk assessment associated with self-administration. EVIDENCE: Care plans sampled gave detailed knowledge of how the resident’s needs were met. Full consultation had been held with the residents of how they would like things done. Personal Health Care, emotional, and physical needs were recorded. When a resident had appointment with other Health Care Professionals details of why and the results were recorded. This was then incorporated into the daily plan of care. One care plan recorded that the resident had an accident and was taken to Hospital. The manager had informed the relevant professional, and CSCI. For a short period of time the resident was monitored and the care plan adapted. Medication risk assessment had been completed however was not specific, for example one resident self administer medication on a Tuesday and Thursday at a day centre he attends all other times staff administer. This information needs to be included in the risk assessment. Action plan received from provider on 10/10/05 indicates compliance. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 14 The medication policy was satisfactory and information was available that gave side effects of the medication taken by residents, and what staff needed to look for. The medication is stored appropriately. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Regular meetings are held to ensure resident views are respected and taken into consideration when making decisions. A more robust procedure needs to be followed pertaining to residents finances to ensure a complete audit of all monies held on behalf of residents. EVIDENCE: Regular meetings with residents are held and include discussions around improvements in the building, CSCI, activities, Holidays, and how the service can improve. General information is also shared with residents about policies and procedure. The home uses the Birmingham Multi Agency Guidelines for Adult Protection. The Manger has expanded on this policy to include a flow chart that gives a step-by-step guide of what to do if an allegation is made. Financial records of residents were sampled. In one residents file it gave the description of what the monies had been spent on, but did not give a running balance, or the amount this resident had to begin with. The manager said she would ensure there was an additional column inserted in to the format to reflect a running balance including the balance carried forward. Action plan received from provider on 10/10/05 indicates compliance. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 Bamville Road meets the needs of the current residents and provides a comfortable, clean and secure environment. EVIDENCE: The manager said Bamville Road would provide a homely non-institutional atmosphere that is suitable to the needs of those who live there. The home was clean and fresh. The manger has submitted plans to the Commission for some renovation work, to include the registration of 3 extra beds. At present, the home would be unsuitable for resident with mobility difficulties as there is a steep fight of stairs to the first floor. In additional to this there is only one bedroom on the ground floor, this has ensuite facilities. It is the intension of the manager/owner to incorporate the bathroom that is situated on the ground floor as part of the renovation once the plans have been agreed. At present, the accommodation is suitable for the present residents. When considering the furnishing for the new bedroom that would registered, the manager must ensure that, these rooms are furnished with at least one comfortable armchair, a chest of draws, separate hanging facilities for cloths, and a table for multi purpose use in additional to the bed and bedside table. There should also be lockable facilities for resident’s private possessions to be secure. A satisfactory infection control procedure and Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 17 arrangements for dealing with clinical waste were in place. All COSHH items were found to be stored appropriately. Polices and procedure were seen for the control of infection including the safe handling and disposal of clinical waste. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36 The Recruitment procedure must be improved to protected residents welfare. Supervision and training is completed and centres on personal development, residents, and policies and procedure. EVIDENCE: Bamville Road meets the needs of the current residents and provides a comfortable, clean and secure environment Staff files were sampled including supervision records. Recruitment files do not contain the relevant information as required by The National Minimum Standards. All staff employed must have information pertaining to: • Full name and address. • Date of birth. • Qualifications, and experiences. • A copy of birth certificate. • A copy of each reference. • The date on which he/she commenced employment. • The position he/she holds. • Job Description. • CRB, and POVA • Application form. • Interview notes. • Photo Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 19 • Medical fitness. Supervision is completed regularly with the manager and include, training evaluation, discussion concerning residents and personal development for staff. Training has been completed in Food Hygiene, First Aid, Manual Handling, Medication, Fire Safety, and NVQ 2 for staff. The deputy manager has recently completed NVQ4, and is commencing the Registered Manger Award. Action plan received from provider on 10/10/05 indicates compliance. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 42 The Health and Safety of residents is not adequately protected in this Home and needs to be improved. Particularly in Fire Safety and ensuring the window restrictors are within the recommended guideline. EVIDENCE: During a tour of the building, it was noted in one resident’s bedroom the window restrictor did not adequately prevent the window opening in excess of the recommended requirements. This must be measured and adequate action taken. All fire safety doors did not close into rebate; action must be taken to rectified this. The manager must complete risk assessments for service users (with specific details on health conditions such as the possibility of self-harm, and aggressive behaviour. Such documentation is subject to regular review or when circumstances change. In general, policies and procedure reflected good practices. Action plan received from provider on 10/10/05 indicates compliance. Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 x x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bamville Road, 1 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x 3 x 3 x E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 22 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 5 Regulation 5(1)(b,c) Requirement Timescale for action 1 October 2005 1 October 2005 2. 6 3. 9 4. 20 5. 23 All residents must have a contract of terms and conditions of residency completed, signed and dated. 13(4) (c ) Care plans must identify specific &15(2)(b) instructions for staff in the management of residents potential to self-harm, and exhibits aggressive behaviour. Action plan received from provider on 10/10/05 indicates compliance. 13 (4) (c ) Risk assessments must identify instruction to staff in the management of a residents potentinal to self-harm, and exhibits aggressive behaviour. Action plan received from provider on 10/10/05 indicates compliance. 13(2) Risk assessments must be 13(4) ( c) completed for residents who Self Administer Medication. Action plan received from provider on 10/10/05 indicates compliance. Schedule A Robust Procedure must be (4) (9) produced for the safe keeping and recording of residents finances. Action plan received from E54 S17076 Bamville House V238387 220805 Stage 4.doc 1 October 2005 1 October 2005 1 October 2005 Bamville Road, 1 Version 1.40 Page 23 6. 34 Schedule (2) 7. 42 23(5) & 13(4) (c ) 8. 42 13(4) (c ) provider on 10/10/05 indicates compliance. A Robust Recruitment Procedure must be completed for all staff employed. Action plan received from provider on 10/10/05 indicates compliance. All Fire Safety Doors must be checked to ensure they close completely in to the rebate. Action plan received from provider on 10/10/05 indicates compliance. All window restrictors must be within the recommended guidelines. 1 October 2005 1 October 2005 1 October 2005 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 Good Practice Recommendations Bamville Road, 1 E54 S17076 Bamville House V238387 220805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Birmingham & Solihull Local 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. 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