CARE HOME ADULTS 18-65
Nevin House 21 Nevin Grove Perry Barr Birmingham West Midlands B42 1PE Lead Inspector
Gerard Hammond Unannounced Inspection 28th March 2006 04:50 Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 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.V287601.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V287601.R01.S.doc Version 5.1 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.V287601.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 20th October 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.V287601.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection of the current year and was unannounced. This report should be read in conjunction with the one written following the inspection completed on 26 October 2005. Direct observations and sampling of records (including care plans, personal files, previous inspection reports and safety records) were used for the purposes of compiling this report. The Inspector was able to meet with all three residents, and obtain their views directly. The Registered Manager was also interviewed formally. A tour of the building was completed. What the service does well: What has improved since the last inspection?
The Manager has made serious efforts to improve care planning and management and is working on introducing a new system to support this. At the time of the inspection, this was a work in progress. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 6 A previous requirement to cross-reference risk assessments with the care plans to which they relate, has now been dealt with. The Manager has begun work on formalising quality assurance and monitoring activity through the introduction of a new system, though this is yet to be implemented. She continues to demonstrate a positive attitude to developing the service for the benefit of the people who use it. 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.V287601.R01.S.doc Version 5.1 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.V287601.R01.S.doc Version 5.1 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): EVIDENCE: Key Standard 2 was assessed at the last inspection and met in full. The three men living in this house have been together as a group for a number of years. There have been no admissions since the time of the last inspection visit. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 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&9 Residents’ needs and aspirations are reflected in their individual plans, and good work already begun to develop these should be continued. Residents are encouraged to maintain and independence through responsible risk taking. EVIDENCE: Key Standards 6, 7 and 9, and Standard 8 were assessed at the time of the last inspection. Standards 7 and 8 were met in full, while Standards 6 and 9 were partially met. Since the last inspection, the Manager has commenced work on introducing a new care plan format. As indicated previously, individual plans contain good quality information and there is evidence that plans are reviewed and updated regularly. There is also evidence of goal setting, but this continues to be an area that could be developed further. In particular, goals set should have outcomes that can be measured, and these should be evaluated when plans are reviewed. However, it is clear that the Manager continues to make positive efforts to improve and develop care management practice, and that this is very much a work in progress and should be continued.
Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 10 enhance their personal It was previously reported that residents were encouraged to take risks in a responsible manner, and that this was seen as an opportunity for learning, growth and personal development. A requirement was made at the last inspection that risk assessments should be cross-referenced with the care plan(s) to which they relate, and this has now been dealt with. The Manager also advised that training is being provided by an accredited organisation so as to develop the team’s awareness and knowledge of personcentred approaches, as recommended by the Government White Paper “Valuing People”. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 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): EVIDENCE: Standards 11, 12, 13, 14, 15, 16 and 17 were all assessed at the last inspection and fully met. All three men continue to access structured activities at the small day centre run by this Organisation. In addition to this they access a wide range of facilities in the community, in accordance with their wishes. In conversation with all of them, they made it perfectly clear that they are very happy with the opportunities they enjoy. They reported that they are now thinking about making plans to go away on holiday later this year, and are looking forward to this very much. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 12 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 Residents receive personal support in accordance with their assessed needs and preferences, and have their healthcare needs met appropriately. EVIDENCE: As previously reported, it is evident that (from direct observations and from speaking with the people living in the house) residents and staff enjoy an excellent rapport and are clearly at ease in each other’s company. Support is given with warmth, friendliness and respect, as appropriate. Residents’ attire and personal grooming provided further evidence that they receive a good standard of basic personal care. The Manager advised that she is in the process of arranging medical reviews with the local GP. It was noted at the time of the previous inspection that personal records contain evidence that residents are supported to access primary and specialist healthcare in accordance with their needs. Conversations with the Manager made it clear that she adopts a very pro-active approach to dealing with related issues. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: Key Standards 22 and 23 were assessed at the last inspection and fully met. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 14 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 & 30 Residents continue to enjoy the benefit of living in a house that is safe, comfortable and homely. Good standards of hygiene are maintained, and the house is kept clean and tidy. EVIDENCE: Key Standards 24 and 30, and Standards 26, 28 and 29 were all assessed at the last inspection and met in full. 21 Nevin Grove is a domestic scale semi-detached house, which has been extended and improved for the benefit of the residents. All three people said that they are very happy in their home. The house is comfortably furnished and provides them with a warm and welcoming home environment: it has a very “lived-in” feel about it. The house is kept clean and tidy, and good standards of hygiene maintained. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 15 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): 32, 34, 35 & 36 Residents are supported by competent staff, but a training and development plan is still required in order to assess fully whether or not the team is appropriately trained. General recruitment policy and practice promote residents’ safety. Arrangements put in place to improve formal supervision should now be implemented and practice brought up to the required standard. EVIDENCE: The Manager advised that two members of the current staff team are qualified to NVQ level 2, and a further 5 are currently working towards this. It was previously reported that the Manager displays a positive attitude towards ensuring that staff have access to good opportunities for training and personal development, and this continues to be the case. However, a staff training and development plan is still required, as indicated at the time of the last inspection, and this must now be provided. As previously advised, this should include (for each member of staff) details of all training completed and qualifications gained to date. Any gaps, including refreshers, should be highlighted and the plan should also show when outstanding training is scheduled, and who is to deliver it. Records relating to staff recruitment were sample checked, and it was noted that CRB checks and other required documentation were in place. It is
Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 16 recommended that the use of a simple checklist management and filing of this information in the future. could improve the The Manager must ensure that all members of staff receive formal supervision at least six times in any twelve-month period (pro rata for part-time staff): this requirement remains outstanding. The Manager advised that supervision had now been delegated to a senior member of staff, and it was anticipated that this issue should be resolved in future. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 17 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, 39 & 42 The home is generally well run. Residents’ views are actively sought. Formal systems for quality assurance and monitoring should now be implemented. General practice promotes the health, safety and welfare of the residents, but one or two items are now in need of attention. EVIDENCE: The Manager advised that she has completed all the units for her NVQ level 4 and Registered Manager’s Award, but is waiting for her assessor to conduct observation and complete certification. As previously reported, her management style is open and inclusive, and she is very much involved in the day-to-day operation of the service. Residents are very clear that they know they can approach her and raise any matters of concern directly with her, and are very comfortable in doing so. The Manager advised that she is looking to develop formal quality assurance and monitoring and has recently purchased a new system to this end. It is
Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 18 clear that residents’ views are actively sought, and evidence of regular residents’ meeting was also seen. Safety records were sample checked. Tests of the fire alarm and emergency lighting systems are generally being done as required, and a written record maintained appropriately. It was noted that the fire risk assessment is due for review in the near future, and that a fire evacuation drill is now also overdue. The Manager indicated that portable appliance testing on electrical equipment had been carried out recently, but the certificate was not to hand on the day of the inspection visit. Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X 3 3 Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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) Requirement Develop care plans as indicated in the main body of this report, to include goals with measurable outcomes, and keep plans and goals under review. (Partially met) Forward an up to date staff training and development plan to CSCI. The plan should contain all the information detailed in the main body of this report. (Outstanding since 31/01/06) Ensure that each member of staff receives formal supervision at least six times in any 12 month period (pro rata for parttime staff) Outstanding since 21/03/05. Review and update the workplace fire risk assessment Carry out a fire evacuation drill, and ensure that residents and staff are aware of the action to be taken in the event of a fire in the home. Ensure that portable appliance testing has been completed on all electrical equipment and forward a copy of the certificate to CSCI.
DS0000017051.V287601.R01.S.doc Timescale for action 30/06/06 2. YA32YA35 18 (1c) 30/06/06 3. YA36 18 (2) 31/05/06 4. 5. YA42 YA42 13 (4c) 23 (4e) 31/05/06 31/05/06 6. YA42 13 (4c) 31/03/06 Nevin House Version 5.1 Page 21 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 YA6 Good Practice Recommendations Seek to incorporate person-centred approaches into future care planning, in keeping with the aspirations of Valuing People. 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). (Not assessed on this occasion) Devise a simple checklist to use with staff files, to ensure that required documentation relating to recruitment has been obtained and is filed appropriately. 2. YA19 3. YA34 Nevin House DS0000017051.V287601.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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