Inspection on 20/10/05 for Nevin House

This inspection was carried out on 20th October 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nevin House 06/03/07

Nevin House 28/03/06

Nevin House 21/03/05

Nevin House 04/02/05

Nevin House 18/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Nevin House 21 Nevin Grove Perry Barr Birmingham West Midlands B42 1PE Lead Inspector Gerard Hammond Unannounced Inspection 20th & 26th October 2005 04:30 Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nevin House Address 21 Nevin Grove Perry Barr Birmingham West Midlands B42 1PE 0121 331 5021 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) Mrs Wendy Steele Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 21st March 2005 Brief Description of the Service: Nevin House is registered to provide accommodation, care and support for three people with learning disabilities. The house is an extended domestic scale semi-detached property, located at the end of a quiet cul-de-sac in a wellestablished residential development in the Perry Barr area of Birmingham. Downstairs is a lounge, conservatory / dining room, kitchen, bathroom and toilet, and one resident’s bedroom. There is also a laundry area, separate toilet and office situated at the back of the house. Upstairs there are two further bedrooms, a shower room, and a small room with comfortable chairs offering a private space to see visitors, or a “quiet room”. There is a small garden at the front of the house. Parking in the cul-de-sac is very limited. However, to the rear of the property is a large garden giving access to an area that can accommodate up to five vehicles. Local shops and parks are located a short walk away from the house, which is also within easy reach of the large “One-Stop” complex at Perry Barr. The area is well served by public transport. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Direct observation and sampling of records (including care plans, personal files and previous inspection reports) were used for the purposes of compiling this report. The Inspector met with all three residents. The Registered Manager was formally interviewed, and a member of support staff interviewed informally. A tour of the premises was also completed. What the service does well: What has improved since the last inspection? Positive efforts have been made to meet requirements set at the time of the last inspection. A complaint against a member of staff has been investigated, and appropriate action taken. The Manager is making progress towards achieving NVQ Level 4 and the Registered Manager’s Award. Aspects of medication management have been improved. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 6 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. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 2 Residents’ individual support needs and aspirations have been appropriately assessed. EVIDENCE: There have been no admissions since the last inspection. The current group of three men have been together for a number of years. An examination of their personal records revealed good quality information about their individual support needs, and provided evidence that these are kept under review as required. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 8 & 9 Residents’ needs and goals are reflected in their care plans, and opportunities should be sought to develop these further. Residents are supported to make decisions about their lives, and are consulted on and take an active part in day-to-day life in the Home. People living in the house are encouraged and supported to take risks in a responsible manner, in order to maintain and enhance their personal independence. Individual risk assessments should be filed appropriately, and clearly linked to relevant care plan(s). EVIDENCE: Two of the three residents’ care plans were sampled. It is clear that a good deal of work has gone into drawing up individual plans, and to ensuring that they are reviewed regularly. Information is of generally good quality. There is also evidence of goal setting, and this is to be commended. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 10 Records examined, and conversations with the Manager indicate that there is a positive attitude towards risk assessment, and that responsible risk-taking is seen as an opportunity for learning, growth and personal development. Conversations with residents provided evidence that they are actively encouraged to make choices about their lives, and that they are very happy with the range of opportunities open to them. In addition to regularly held residents’ meetings, they are consulted on a day-to-day basis. Direct observation made it quite clear that this is a group of people that are well able to make their wishes known, and do so frequently. Whilst acknowledging the good work that has been done in care planning and risk assessing, there are areas where some adjustments could lead to significant improvement. Consideration should be given to how care plan information is managed and presented, in order to make important information more readily accessible and easier to locate. For example, risk assessments should be directly cross-referenced with the care plan(s) to which they relate, and vice versa. Numbering and indexing plans and assessments will facilitate this process. Individual risk assessments should only be held on the personal records of the person to whom they relate, in order to comply with current data protection legislation. Goal setting should be developed, so that targets have outcomes that can be measured. These should then be evaluated at review, and judgements made about what has worked and what might need to be changed. Whole care plans should be reviewed at least every six months, with written records kept, indicating who takes part and how decisions are made. It is further recommended that consideration be given to ways in which care plans can be structured so as to make tracking specific information easier. This is particularly important in situations where new staff or agency personnel might be on duty. In addition, it is also recommended that future planning should seek to develop the use of person-centred approaches, in keeping with the aspirations of the Government White Paper “Valuing People”. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Residents are able to take part in appropriate activities of their choosing, and enjoy opportunities for education and learning, personal development, social and leisure pursuits and for being part of the life of the local community. People are well supported to keep in touch with their families and friends. Residents’ rights are respected, and they are encouraged to be as independent as they are able. They have access to a balanced, nutritious diet and enjoy their food. EVIDENCE: The residential care service offered at Nevin House is part of an integrated service providing structured day activities as well. The Manager and care team run a small day service away from the Home. All of the residents attend a small day centre, which is also used by other members of the community currently living at home with their families. In addition to this, residents also attend a local college on two days during the week. Their activity programme Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 12 is varied and includes opportunities for education, learning new skills, and a range of social and leisure pursuits also. All three residents were enthusiastic about the programme of activities available to them, and were very clear that they enjoyed taking part. They said that apart from their regular activities, they enjoyed going out to play snooker, pool or darts, visiting the cinema, and going swimming. They also enjoy getting meals in from the local Chinese Takeaway, and said that they liked going to the local barbers when they needed a haircut. At home they said they liked watching TV “soaps”, as well as horse racing and football. They reported that they felt able to do all the things that they wanted, and were very happy in their home. Residents are also well supported to keep in touch with their families and friends, through visits and telephone calls. One resident regularly goes to stay with his family at the weekend. People living in the house are encouraged to do as much for themselves as they can. They have free access to the whole of the house. They also reported that they enjoyed the food they got, and could have what they wanted. The record of meals provided evidence that people have access to a diet that is sufficiently varied, balanced and nutritious. Food stocks were plentiful and included fresh produce. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 & 20 Residents receive personal support in accordance with their assessed needs and preferences, and have their healthcare needs met appropriately. General practice in relation to the storing, handling and administration of medication affords appropriate protection to the people living in the house. EVIDENCE: It is clear from direct observation and from conversations with the people living in the house, that residents and staff enjoy an excellent rapport, and are very comfortable in each other’s company. The household has an “extended family” feel about it. Residents expressed their satisfaction with the personal care and support they receive, and staff were seen interacting with residents in a warm and friendly manner, that was appropriately respectful. Personal records and previous inspection reports provided evidence that residents are supported to access primary and specialist healthcare, in accordance with their needs. The accident book was examined, and is in a format that complies with the requirements of current data protection legislation. Incident reports have been completed in detail, but should also confirm what action was taken. It is also recommended that the accident policy and accident book have a prominent note inserted to alert staff to the need to submit reports required under Regulation 37 (Care Homes Regulations 2001). Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 14 This service uses the Boots Monitored Dosage System; each resident has his own secure medication cabinet in his bedroom. At the time of the last inspection one resident was self-administering his medication under appropriate supervision. Changes to his medication have meant that this is not currently possible, and the Manager is seeking discussion with the relevant Doctor with a view to prescribing the medication in a form that he can manage, so as to enhance his personal independence. Protocols are in place with regard to the administration of PRN (“as required”) medication and the Medication Administration Record had been completed appropriately. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 Residents state that their opinions are valued, and concerns raised are taken seriously and acted upon. General practice offers residents protection from abuse, neglect and self-harm. EVIDENCE: The people living in this house are well aware of their right to complain, and have exercised this in the recent past. They said that they knew they could talk to the manager about anything that concerned them. The previous inspection report recorded a complaint that was brought with regard to the attitude and actions of a member of staff. The matter was investigated subsequently, and appropriate action taken. The adult protection policy is in line with, and incorporates, the local multiagency guidelines on protecting vulnerable adults. Conversations with the Manager indicate that she is aware of the relevant issues and fully prepared to take action required. It was not possible on this occasion to assess fully the position with regard to training received by the staff team in adult protection matters (see Standard 35 also). Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 the following standard(s): 24, 26, 28, 29 & 30 Residents enjoy the benefit of living in a house that is safe, comfortable and homely. Residents’ bedrooms provide independence and privacy. them with opportunities for personal Communal spaces are sufficient for residents’ needs, and complement their own rooms. Specialist equipment required to support individual independence is provided in accordance with assessed needs. The home is clean, tidy and hygienic. EVIDENCE: As reported earlier, 21 Nevin Grove is a domestic scale semi-detached house that has been extended and improved for the benefit of the people living there. The house is warm, welcoming and comfortable, and the three residents all said they enjoyed living in their home. They were very keen to show the Inspector their own rooms, which are individually styled and comfortably furnished, with personal possessions and effects in evidence. Some of the Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 17 residents have their own televisions and DVD / video players and music systems in their rooms if they wish to use them, but they said they generally like to be together in the lounge most of the time, when they are relaxing at home. One resident does not manage stairs, but his room and the bathing facilities are all on the ground floor. The bathroom is also equipped with a hoist. Though not excessively spacious, the communal areas are sufficient at this time for the needs of the current resident group. In addition to the lounge and conservatory / dining room, there is a small room upstairs that can be used as a “quiet” room, or to see visitors in private. The house is kept neat and tidy, and a good standard of hygiene maintained. Laundry facilities are situated away from food preparation areas. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 & 36 A training and development plan is required to judge accurately whether or not the care team is trained appropriately. Arrangements for formal supervision need to improve. EVIDENCE: An up to date staff training and development assessment and plan is required, in order to judge appropriately the needs and strengths of the care team. The plan should include (for each member of staff) details of all qualifications gained and training completed to date, and highlight any gaps (including “refreshers”). The plan should show when outstanding training is scheduled, and who is to deliver it. It should be acknowledged that the Manager displays a positive attitude towards ensuring that staff have good opportunities for training and personal development. At the last inspection, a requirement was made that formal supervision of all staff should take place at least six times in any twelve-month period, and this remains outstanding. The Manager advised that she is seeking to delegate this responsibility in order to ensure that the requirement is met in the near future. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 & 42 The home is generally well run for the benefit of the people living there. The management style is open and inclusive. General practice promotes the health, safety and welfare of the residents. EVIDENCE: The Manager is still working towards attaining NVQ Level 4 and the Registered Manager’s Award, and now hopes to have completed this early in 2006. Direct observation confirmed that she has a very “hands-on” approach to her role, and that her management style is both open and inclusive. She demonstrates a very positive attitude towards developing the service for the benefit of the people who use it. It is clear that residents are very comfortable with her, and that they find her to be an approachable person. Safety records were sample checked. The fire alarm, emergency lighting system and fire-fighting equipment have all been serviced. The fire risk Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 20 assessment has been reviewed, and there is a complete record of weekly testing of the alarm and emergency lighting systems. Fire evacuation drills have been carried out at six-monthly intervals as required. Portable appliance testing has been carried out on electrical equipment, and the five-year hard wiring certificate is in date. Tests have been carried out of the fridge and freezer temperatures, and a record kept as required. Packages of food stored in the fridge have been labelled with the date of opening. Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 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 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Nevin House Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000017051.V260946.R01.S.doc Version 5.0 Page 22 YES 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 YA6 Regulation 15 (1-2) Timescale for action Develop care plans as indicated 31/01/06 in the main body of this report, to include goals with measurable outcomes, and keep plans and goals under review. Cross-refer risk assessments 31/01/06 with the care plan(s) to which they relate. File risk assessments relating to named individuals on their personal records only. Forward an up to date staff 31/01/06 training and development plan to CSCI. The plan should contain all the information detailed in the main body of this report. Ensure that each member of 31/01/06 staff receives formal supervision at least six times in any 12 month period (pro rata for parttime staff) Outstanding since 21/03/05. Requirement 2 YA9 13 (4) 3 YA35 18 (1c) 4 YA36 18 (2) Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 23 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 2 3 Refer to Standard YA6 YA9 YA19 Good Practice Recommendations Seek to incorporate person-centred approaches into future care planning, in keeping with the aspirations of “Valuing People”. Number and index risk assessments and care plans, to support cross-referencing and to make it easier to locate important information. Insert a prominent note in the accident book and the accident policy alerting staff of the need to make reports to CSCI under Regulation 37 (Care Homes Regulations 2001). Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 24 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 Nevin House DS0000017051.V260946.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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