Inspection on 07/03/05 for Mercian House

Care Homes For Adults (18 – 65)Bamville Road (1)Ward End Birmingham West Midlands B8 2TJUnannounced Inspection7th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Bamville Road (1) Address Ward End, Birmingham, West Midlands, B8 2TJ Email address Name of registered provider(s)/company (if applicable) Mrs Janice Hutton Mr Festus Hutton Name of registered manager (if applicable) Mrs Janice Hutton Type of registration Care Home No. of places registered (if applicable) 3 Tel No: 326 0491 & 688 5797 Fax No: 688 5797Category(ies) of registration, with (number of places) Learning disability over 65 years of age (3) Registration number E060000040 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspection Date of latest registration certificate 30th July 2002 YES NO 15/12/04 If Yes refer to Part CBamville Road (1)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector Name of inspector 1 2 3 47th March 2005 2.45pm Susan Scully Brenda O’NeillID Code145480Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJ HuttonBamville Road (1)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementBamville Road (1)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Bamville Road (1). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • • • • • • • • Inspection methods used Key findings and evidence Overall ratings in relation to the standards Compliance with the Regulations Required actions on the part of the provider Recommended good practice Summary of the findings Providers response and proposed action plan to address findingsThis report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Bamville Road (1)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED 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 is 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)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The focus of inspections undertaken by the Commission for Social Care Inspection is upon the views and experiences of service users, and the ability of the service to support and promote their health and wellbeing. This is the second inspection of this service in the 2004/05 Inspection Year. Linked to the Commission’s focus on service user experience and proportionate inspection, this inspection will focus on requirements outstanding from the last inspection of this service on 15 December 2004, and National Minimum Standards that have the greatest direct impact on the health, wellbeing and opportunities of service users. At the time of the visit the inspectors had the opportunity to speak with service users. The Home was clean and fresh with good decor. The Inspectors would like to thank service users for their contribution made during the visit. Choice of Home (Standards 1 – 5) The Manager had made some amendments to the care plans that showed how the Home intended to meet the service users needs. The Manager told the Inspectors that all care plans were being reviewed and relevant information being put in. The Manager had complied an index to indicate what would be contained in each individual care plan. The Inspectors did not assess the assessment process, as the Home has had no new admission for a number of years. The Manager must assess all new service users. The Manager must write to the service user indicating that after the initial assessment the Home can meet the service users needs. Individual Needs and Choices (Standards 6 – 10) The Manager had redeveloped the care plans since the last inspection. Information contained in the care plan sampled by the Inspectors included: picture symbols, how the service user wanted to be cared for, visits to hospitals, dentist, and doctors. Information regarding his personal care, and what mobility aids are used. The Manager told the Inspectors she was reviewing all care plans. When complete these will be assessed at the next inspection. The Manager must ensure that proactive and reactive strategies are also included in the care plans as the statement of purpose indicates the Home can meet the needs of service user with mild behavioural needs. The Inspectors were please with the progress that had been made to the care plans. Lifestyle (Standards 11 – 17) The service user’s diary sample during the visit indicated that service users go out each day to various locations. Service users also attend a day centre. One service user told the Inspector that they go out with the Manager for a meal once a week. The Inspector did not evidence other activities that service user participate in. On the day of the visit one service user was helping to prepare the tea. The Manager must ensure that all service users participate in fulfilling activities. An activities program must be draw up for all service users as part of their assessed needs. Bamville Road (1) Page 6 Personal and Healthcare Support (Standards 18 – 21) Care files sampled by the Inspector showed service users have access to other health professional, such as dentist, GPs, hospital appointments, optician, and chiropody. One care plan indicated that a service user was diabetic. The Manager told the inspectors that this was not the case. This information was shown in the service users care plan. The Manager told the inspectors that care plans were being reviewed and this would be omitted from the care plan, as it no longer applies. Concerns Complaints and Protection (Standards 22 – 23) The Home has an Adult protection policy that does not meet the Department of Health Guidelines on No Secrets and the Birmingham City Council Multi Agency Guidelines. The Manager must review the procedure and forward a copy to the CSCI. The Inspector sampled records pertaining to service user monies held at the Home. Records did not show all the income and expenditure of the service users monies. This was discussed at length with the Manager at the time of the visit. The Manager must complete an audit of all monies coming into the Home. The records must have a running balance with receipts for all expenditures. Environment (Standards 24 – 30) The Home was clean and fresh. The inspectors were pleased to see the requirements from the last inspection had been met. At the time of the visit the Home was being decorated. The action plan sent to the commission from the last inspection was discussed. The Manager had indicated that the outside toilet would not have a lock fitted that could be overridden in the event of an emergency. The reason was that this toilet was going to be used by staff. It is a requirement of this inspection that the Manager ensures that no service users use the toilet outside unless a suitable lock is fitted. This lock must be suitable to open in the event of an emergency. Staffing (Standards 31 – 36) The Inspector did not sample records pertaining to staff at this visit. The Home appeared to be relaxed and service user were seen to interact well with the Manager. Conduct and Management of the Home (Standards 37 – 43) The Manager told the Insectors it was her intension to ensure that service users needs were met. The Home was clean and service user told the Inspector there were happy at the Home. The service users go on holiday with the Manager and the last holiday was a trip to Jamaica. It was the intension to go again. One service user told the Inspectors that the Manager looks after them well and was always approachable.Bamville Road (1)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action The home must develop comprehensive care plans following consultation with service users, that meet all aspects of service users needs; such documentation is subject to review at least every six months or when circumstances change. The home must document within the care plans the process regarding the right of service users to make informed decisions. The home must demonstrate how service users are encouraged and offered opportunities to participate in the day-to-day running of the home and to contribute to relevant policies and procedures. The home must undertake risk assessments for service users (with specific details on health conditions such as Epilepsy, Diabetes and Poor Mobility), staff, the premises, food, and fire and infection control. Such documentation is subject to regular review or when circumstances change. All risk assessments must be dated and signed by staff and service user if possible and / or next of kin.115 (1) (2) (a) to (d)YA6212 (2)YA7324 (1) (a) & (b)YA8413 (4) (a) to (c)YA9YA4517(2) schedule 4 18 (1) (a)YA33The home must collate the duty rota to comply with the Working Time Regulations 1998.Bamville Road (1)Page 8 619 (1) to (5) Schedule 2 17(2) Schedule 4(6)(e)YA34The home must operate a robust recruitment system by obtaining completed application form, two satisfactory references, photocopies of birth certificate and passport, a photograph and CRB check before employment is offered. The home must develop and provide all staff with job descriptions. The home must provide a structured programme of induction that reflects the content of the LDAF training and demonstrate that such has been carried out. The home must document the opportunities offered to service users to maintain and develop social, emotional, communication and independent living skills. Staff must receive training in Adult Protection by a person competent to do so and a record of such training must be maintained for inspection. Staff must receive formal supervision at least six times per year (pro rata for part time staff) that is fully documented; an annual appraisal must also be included. The home must provide each service user with a contract/statement of terms and conditions as specified within Standard 5.2. Activity programmes must be developed for service users that includes information of how the Service User was assessed and what outcome the activity is to achieve. The home must complete a Risk Assessment for any Service User self administering medication, ensuring regular reviews take place, this must also include Compliance Checks. The lock on the door in the outside toilet must be removed and replaced with a lock that can be overridden in the event of an emergency.7YA31818 (1) (c)YA35916 (2) (m)YA111018(1) 13 (6)YA231118 (2)YA36125 (1) (c)YA51316(m)(n)YA111413(2)YA201513(4)(a) (c)YA27 YA42Bamville Road (1)Page 9 Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Bamville Road (1)Page 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The home must develop comprehensive care plans following consultation with service users, that meet all aspects of service users needs; such documentation is subject to review at least every six months or when circumstances change. The home must document within the care plans the process regarding the right of service users to make informed decisions. The home must demonstrate how service users are encouraged and offered opportunities to participate in the day-to-day running of the home and to contribute to relevant policies and procedures. This standard not inspected. The home must undertake risk assessments for service users (with specific details on health conditions such as Epilepsy, Diabetes and Poor Mobility), staff, the premises, food, and fire and infection control. Such documentation is subject to regular review or when circumstances change. All risk assessments must be dated and signed by staff and service user if possible and / or next of kin.115 (1) (2) (a) to (d)YA61/5/05212 (2)YA71/5/05324 (1) (a) & (b)YA81/5/05413 (4) (a) to (c)YA9YA421/5/05Bamville Road (1)Page 11 517(2) schedule 4 18 (1) (a)YA33The home must collate the duty rota to comply with the Working Time Regulations 1998. This standard not inspected. The home must operate a robust recruitment system by obtaining completed application form, two satisfactory references, photocopies of birth certificate and passport, a photograph and CRB check before employment is offered. This standard not inspected.1/5/05619 (1) to (5) YA34 Schedule 21/5/05717(2) Schedule 4(6)(e)YA31The home must develop and provide all staff with job descriptions. This standand not inspected. The home must provide a structured programme of induction that reflects the content of the LDAF training and demonstrate that such has been carried out. This standand not inspected. The home must document the opportunities offered to service users to maintain and develop social, emotional, communication and independent living skills. This standard not inspected.1/5/05818 (1) (c)YA351/5/05916 (2) (m)YA111/5/051018(1) 13 (6)YA23Staff must receive training in Adult Protection by a person competent to do so and a record of such training must be maintained for inspection. Staff must receive formal supervision at least six times per year (pro rata for part time staff) that is fully documented; an annual appraisal must also be included. This standard not inspected. The home must complete a Risk Assessment for any Service User self administering medication, ensuring regular reviews take place, this must also include Compliance Checks. This standard not inspected.1/5/051118 (2)YA361/5/051213(2)YA201/5/05Bamville Road (1)Page 12 1316(m)(n)YA12Activity programmes must be developed for service users that includes information of how the Service User was assessed and what outcome the activity is to achieve. The statement of purpose requires amendment to include: • The number and size of rooms in the home • Details of any specific therapeutic techniques used and arrangements made for their supervision. The Manager must assess all new service users. The Manager must write to the service user indicating that after the initial assessment the Home can meet the service users needs. The Manager must review the Adult Protection policy to comply with the department of Health Guidelines on No Secrets and the Birmingham City Council Multi Agency Guidelines. The Manager must complete an audit of all monies coming into the Home. The records must have a running balance with receipts for all expenditures. The Manager must review the menus to give a balanced and nutritional diet. Information pertaining to aliments, disabilities, or medical conditions that no longer apply to service users must have evidence that a review has taken place to indicate a professional diagnosed has been completed. A suitable lock must be fitted to the outside toilet. The Manager ensures that no service users use the toilet outside unless a suitable lock is fitted. This lock must be suitable to open in the event of an emergency.1/5/05144(1) (a)(b)(c )YA11/5/051514(1)(a)(d)YA31/5/05YA42 16 13(4)(c ) YA39 YA23 Schdule 4 (9) 16(2) (i)1/5/0517YA231/5/0518YA171/5/051914(2) (b) 15(2) (b)YA191/5/052013(4)(a) (c)YA42 YA241/5/05RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard Bamville Road (1) Page 13 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Bamville Road (1)Page 14 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO YES NO YES NO NO YES NO NO NO YES NO YES 2 0 0 NO NO YES YES X 0 07/03/05 14:45 2.5Bamville Road (1)Page 15 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Bamville Road (1)Page 16 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. Range of fees charged From To £ X X £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? The Inspectors were given a copy of the Statement of Purpose to take away. The inspectors told the Manager that once the Statement of Purpose had been looked at then the inspectors would put what was required in the body of the report. The statement of purpose requires amendment to include: • The number and size of rooms in the home • Details of any specific therapeutic techniques used and arrangements made for their supervision. The Manager has applied to the Commission to extend the service to six registered beds this is under discussion. The service user’s guide was not shown to the inspectors at the time of the visit.Bamville Road (1)Page 17 Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was met at the last inspection and not reassessedStandard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? The Manager had made some amendments to the care plans that showed how the Home intended to meet the service user’s needs. The Manager told the Inspectors that all care plans were being reviewed and relevant information being put in. The Manager had complied an index to indicate what would be contained in each individual care plan. The Inspectors did not assess the assessment process, as the Home has had no new admission for a number of years. The Manager must assess all new service users. The Manager must write to the service user indicating that after the initial assessment the Home can meet the service users needs. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The Statement of Purpose indicates that all service users are invited to the Home for an over night stay. The inspectors could not assess if this takes place, as there has been no new admission to the Home for a number of years.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The Inspector was shown a contract that includes a contribution to the vehicle of the Home. The Manager must ensure that the finances of service user give a running expenditure of all income and expenditure. The inspectors did not see all individual contracts and this will be assessed at the next inspection.Bamville Road (1)Page 18 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • 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. Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? The Manager had redeveloped the care plans since the last inspection. Information contained in the care plan sampled by the Inspectors included: picture symbols of how the service user wanted to be cared for, visits to hospitals, dentist, and doctors. Information regarding his personal care, and what mobility aids are used. The Manager told the Inspectors she was reviewing all care plans. These will be assessed at the next inspection. The Manager must ensure that proactive and reactive strategies are also included in the care plans as the Statement of Purpose indicates the Home can meet the needs of service users with mild behavioural needs. The inspectors were please with the progress that had been made to the care plans. Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? Service users told the Inspectors they make decisions for themselves. One service user told the inspectors that they had been on holiday to Jamaica and how he had enjoyed the holiday and was going again. The Inspectors did not see evidence of how service users make decisions for themselves when sampling service users files. The Manager told the Inspector that all service users choose what they want to do. One service user gave verbal feedback to the inspectors with regards to going to bed, getting up and watching football on TV. The Manager must ensure that service user have the opportunity to participate in any decisions making that involves their welfare, based on a risk assessed frame work. The inspectors did not evidence service users meeting at this visit.Bamville Road (1)Page 19 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? The Manager told the inspectors that all care plans were being reviewed. Sampling records indicated that progress had been made with the recording of information. Risk assessment was not evidenced. The Manager must ensure that risk assessments are completed for all service users. Risk assessment must show how the risk is managed, monitored and reviewed on a regular basis.Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standand not assessed.Bamville Road (1)Page 20 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 2 Key findings/Evidence Standard met? The service users diary sampled during the visit indicated that service users go out each day to various locations. Service users also attend a day centre. One service user told the Inspector that they go out with the Manager for a meal once a week. The Inspector did not evidence other activities that service user participate in. On the day of the visit one service user was helping to prepare the tea. The Manager must ensure that all service users participate in fulfilling activities. An activities program must be draw up for all service users as part of there assessed needs. Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? This standard not assessed.Bamville Road (1)Page 21 Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standand not assessed.0Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? One service user told the inspectors that they could have visitor when they wanted. Evidence seen in care plans indicated that service users maintain family links. Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The routine of the Home appeared relaxed at the time of the visit. Service users told the Inspectors they make choice with regards to going to bed and getting up of a morning. One service user was helping to prepare the tea on the day of the visit.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The Manager gave the inspectors a copy of the menu; Monday to Friday there is a choice of cereals, toast for breakfast. The service users attend a day centre where they have their main meal. Indicated on the menu is a set tea with supper referring to the service users choice. Two days of the week fish and chips or pie and chips is available. There is no choice indicated on the menu for tea. The Manager must ensure an alternative is offered. The menu given to the Inspectors does not indicate a nutritional diet is being provided. The Manager must review the menus to give a balanced and nutritional diet.Bamville Road (1)Page 22 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX1 Key findings/Evidence Standard met? Care files sampled by the Inspector showed service users have access to other health professionals, such as dentist, GPs, hospital appointments, optician, and chiropody. One care plan indicated that a service user was diabetic. The Manager told the inspectors that this was not the case. This information was shown in the service users care plan. The Manager told the inspectors that care plans were being reviewed and this would be omitted from the care plan, as it no longer applies. Information pertaining to aliments, disabilities, or medical conditions that no longer apply to service users must have evidence that a review has taken place to indicate a professional diagnosed has been completed.Bamville Road (1)Page 23 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standand not assessed.Bamville Road (1)Page 24 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard not assessed. X X X X X X 100 Standard met? 0Bamville Road (1)Page 25 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES01 Key findings/Evidence Standard met? The Home has an Adult Protection Policy that does not meet the Department of Health Guidelines on No Secrets and the Birmingham City Council Multi Agency Guidelines. The Manager must review the procedure and forward a copy to the CSCI. The Inspector sampled records pertaining to service user monies held at the Home. Records did not show all the income and expenditure of the service users monies. This was discussed at length with the Manager at the time of the visit. The Manager must complete an audit of all monies coming into the Home. The records must have a running balance with receipts for all expenditures. All staff must receive training in Adult Protection.Bamville Road (1)Page 26 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The Home was clean and fresh. The inspectors were pleased to see the requirements from the last inspection had been met. At the time of the visit the Home was being decorated. The action plan sent to the commission from the last inspection was discussed. The Manager had indicated that the out side toilet would not have a lock fitted that could be overridden in the event of an emergency. The reason was that this toilet was going to be used by staff. It is a requirement of this inspection that the Manager ensures that no service users use the toilet outside unless a suitable lock is fitted. This lock must be suitable to open in the event of an emergency.Bamville Road (1)Page 27 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard not assessed. YES NO NO 3 1 0 X Standard met? 0 XXX X 0 0Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 0 Key findings/Evidence Standard met? This standard not assessed.Bamville Road (1)Page 28 Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standand was met at the last inspection and not reassessed at this visit.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? At the time of inspection the home was found to be clean and fresh. A satisfactory infection control procedure and arrangements for dealing with clinical waste were in place. All COSHH items were found to be stored appropriately. Polices and procedure were seen by the inspector for the control of infection including the safe handling and disposal of clinical waste.Bamville Road (1)Page 29 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 0 Key findings/Evidence Standard met? This standard not assessed.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard not assessed.Bamville Road (1)Page 30 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme Key findings/Evidence This standard not assessed. X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXStandard met?0Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? The Inspectors did not evidence the recruitment records at this visit. Requirements therefore carried forward.Bamville Road (1)Page 31 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 0 Key findings/Evidence Standard met? The Inspectors did not evidence the recruitment records at this visit. Requirements therefore carried forward.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard not assessed.0Bamville Road (1)Page 32 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO 0Key findings/Evidence Standard met? The inspectors did not acert the Manager quaifications at this visit.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard not assessed.Bamville Road (1)Page 33 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The inspectors did not evidence that a qauailty assurance monitor system was in place. The Manager must ensure the views of service user are recorded.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 2 Key findings/Evidence Standard met? The inspectors sampled three policies that appeared to be adequate to ensure the well being of the service users. The Home has a number of policies that have been completed. The inspectors did not examine all the policies required by this standand. The Home has an Adult Protection Policy that does not meet the Department of Health Guidelines on No Secrets and the Birmingham City Council Multi Agency Guidelines. The Manager must review the procedure and forward a copy to the CSCI.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard not assessed.Bamville Road (1)Page 34 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The inspectors sampled records pertaining to Fire Safety, Adult Protection, and the testing of electrical appliances. The Adult Protection policy requires amendment to comply with the Department of Health Guidelines on No Secrets and the Birmingham City Council Multi Agency Guidelines. The Manager must review the procedure and forward a copy to the CSCI. Fire Safety records were satisfactory and in date. The Manager had forwarded a copy of the electrical testing of appliances to the Commission. The manager must complete risk assessments for service users (with specific details on health conditions such as Epilepsy, Diabetes and Poor Mobility), staff, the premises, food, and fire and infection control. Such documentation is subject to regular review or when circumstances change. Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard not assessed.Bamville Road (1)Page 35 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorSusan Scully Brenda O’NeillSignature Signature SignatureRegulation Manager Graham Martin Date 31/03/05Public reports It should be noted that all CSCI inspection reports are public documents.Bamville Road (1)Page 36 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 7th March 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBamville Road (1)Page 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required Action plan was received at the point of publication Action plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan Other: enter details here YES NOBamville Road (1)Page 38 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Bamville Road (1)Page 39 Bamville Road (1) / 7th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000017076.V208536.R01© This report may only be used in its entirety. 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