Inspection on 06/03/07 for Nevin House

This inspection was carried out on 6th March 2007.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nevin House 28/03/06

Nevin House 20/10/05

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 Monica Heaselgrave Key Unannounced Inspection 6th March 2007 09:30 Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 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.V326984.R01.S.doc Version 5.2 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.V326984.R01.S.doc Version 5.2 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 Mrs Wendy Steele Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 28th March 2006 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 service users’ 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 office. 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. The current charge for living at the home is £235.00 per week, basic fee. Additional fees apply. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork of this unannounced key inspection took place over approximately five hours. The inspector collected information in a number of ways; she spoke to the people who lived there, the manager, and care staff. Service users and staff records were looked at, along with records relating to the management of the home, recruitment, training, and work patterns of staff were examined. Medication records and stocks were sampled. The inspection focused on the last requirements and recommendations and what progress had been made towards these since the last inspection. A tour of the building was undertaken, and the procedures in place to protect the health and safety of service users were explored. What the service does well: What has improved since the last inspection? A new care plan format has been introduced which when completed, will enable staff to describe the exact needs of the service user, and detail the type and level of support needed. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 6 A previous requirement to cross-reference risk assessments with the care plans to which they relate, has now been dealt with. A quality assurance and monitoring system has been implemented which has enabled the manager to audit all aspects of service delivery. Service users benefit from the improvements made as a result of these findings. New arrangements for formal staff supervision have been implemented so that practice is up to the required standard. Staff training needs have been assessed and planned for; ensuring they are supported in developing the skills necessary to carry out their care role. What they could do better: Good work already done to develop care plans should be continued. In particular goals set should have outcomes that can be measured, and these should be evaluated when the plan is reviewed. Opportunities for service users to maintain their independent living skills must be included in their care plan. Where these opportunities exist in the day care setting, for the planning, preparation and cooking of meals, and house keeping tasks, the care plan should actively support this. The intervention plan in place to minimise self-harm must be consistently followed, and reporting procedures improved. The reporting of incidents and accidents to the Commission must be improved to ensure the safety and well being of service users. Some areas of the house require minor repairs and or redecoration. These must be addressed to promote the safety and comfort of service users. The staff training profile indicates that some refresher training is required. Proposals to address this are underway, the manager must ensure that the training programme is carried out. A development plan for each staff member is required, demonstrating how the care team’s training achievements and needs will be addressed. The outcome of the fire risk assessment must be developed into a fire action plan showing the control measures in place to protect service users. Some good work has already been done in implementing a quality assurance system. The manager should now explore how the outcome of this work is fed back to service users and other interested parties. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 8 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.V326984.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements suggest that admission assessments are carried out to ensure that the home is able to meet the needs of the prospective service user. EVIDENCE: The three men living in this house have been together as a group for a number of years there have been no admissions throughout this time. The process for admissions appeared to be adequate. An assessment is supplied to the home from a social worker, the manager carries out an assessment before a placement is offered. Three care files were examined and showed that the assessment information formed the basis of the care plan. Care plans provided lots of good information about individual needs, preferences likes and interests, and the manner in which staff will support this. This has meant that the service users expectations and aspirations can be met by the home. It was positive to see that the service user is central to this process so ensuring everyone knows what to expect from the home. Discussion with the manager indicated that she is aware of the steps to be taken for a re-assessment of need should the service users needs change and they require alternative accommodation. Such practices indicate that the home demonstrates its capacity to meet assessed needs of the current people living there. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 10 Conversations with service users confirmed that they had sufficient information about Nevin House before they made the choice to move in. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are set out in care plans, ensuring staff know how to support them. Service users are supported in taking some risks as part of an independent lifestyle, but this could be developed further. EVIDENCE: Since the last inspection, the manager has commenced work on drafting a new care plan format. Current care plans contain some good information and are reviewed and updated regularly, these now need to be completed in full for each service user using the new format adopted. It was previously reported that service users 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 has been provided by an accredited organisation to develop the team’s awareness and knowledge of personcentred approaches, as recommended by the Government White Paper “Valuing People”. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 12 Three service users’ care plans were examined and showed that all aspects of the service users daily living activities are covered, looking at each need the service user presents, and how this will be supported. Risk assessments were cross-referenced, as were daily records. Some concerns were noted in the lack of appropriate follow up for some incidents which were concerning. This was discussed at length with the manager for immediate attention. The manager must ensure that all staff actively follows the strategies in place for managing behaviour. This will ensure the safety of the service user. An Immediate Requirement Report was left with the manager specifying the immediate action to be taken. Further comments are found later in this report regarding notification to the Commission. Service users are supported to make decisions about their lives, this includes activities they take part in, how they celebrate festive events and birthdays. Appropriate risk assessments were seen to be in place for to meet the specific needs of one service user. This person is prone to falls and due to the nature of medication being taken for a medical reason, requires fluid intake to be monitored. The inspector was satisfied that night care arrangements were in place, and that the G.P. oversees the health care arrangements. It was positive to see that service users are supported to shop, and travel independently, however service users comments indicated that much is done for them such as making drinks, cooking, and making snacks. They informed the inspector that staff does these, as it is too dangerous for them. This was discussed with the manager who said that many of these opportunities are made available within the day care setting, in which service users can develop and retain their independent skills. However she recognised that some staff required further input in relation to enabling service users, as apposed to doing everything for them. There is a need for this aspect of the service to be reviewed and ensure that service users are supported to engage in tasks and activities appropriate to their level of ability and capacity, within a risk assessment framework, The three service users confirmed that they exercise decisions about the food they eat, the activities they engage in, and their personal care routines. All three men made positive comments about their experiences; ’I love living here’. ‘ I get to do lots of things I enjoy, such as going to college, going to day care, I like shopping with the staff’. ‘ I’ve been on holiday twice to Spain which was great.’’ I really like being able to talk to the staff, they are really good to me.’ Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to undertake interesting activities in the community are evident ensuring service users can enjoy a meaningful lifestyle. Service users are supported to stay in touch with people who are important to them. Meals are varied and nutritious, and meet with the approval of the service users. EVIDENCE: Lifestyle aspirations vary according to the age, interests as well as levels of ability of people. The three service users have spent many years living as a group, and have some set patterns and routines that suit their age and preferences. In discussion with them they describe a varied social life, which they feel meets their needs. Personal records and conversations with service users showed that people are able to engage in activities of their choosing, this included attendance at local centre, and college. A range of community amenities are also utilised these included; shopping, theatres, church, library, restaurants, cinema, and planned Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 14 trips. The staff had supported service users to have two holidays abroad to Spain. Service users were particularly pleased with these experiences. On the day of the fieldwork visit it was positive to see that the service users were all engaging in different activities. Some were going to their day care placement, and one was going to college. One service user said, ‘’I travel by myself on the bus to college and do lots of interesting things, some days I attend the day care centre which I also enjoy.’ It was particularly pleasing to see that staff via the key-worker system, consult regularly with the service users, in order to see if there are activities they wish to pursue. One service user described that he has support to manage his money, and bus pass to travel independently. He also enjoyed visiting the shops. Another service user said ‘I like going on holiday and shopping.’ In conversation with all of them, they made it perfectly clear that they are very happy with the opportunities they enjoy. It was pleasing to see that where individuals had chosen not to attend college an alternative arrangement for day care had been put in place. The ages of the service users may lead to further changes in terms of retirement options and the manager is aware that these may need to be explored in the future. Good attempts had been made to establish a weekly activities programme, to provide fulfilment and some structure for the service users. Daily records sampled generally reflected that service users had utilised community-based amenities to include; the library, swimming, church, and shopping trips. Service users said that they could talk to staff if they were not happy with their plan, and that service user meetings were a good way to explore social activities and planned trips. It was pleasing to note that service users were supported to maintain contact with their relatives. There are no rigid rules or routines those service users observed all had their own individual plan for the day, this included social/educational commitments. Service users said that meals are prepared and cooked for them by staff, and drinks made. There was little to show that service users have these opportunities within the residential setting. Staff said that skills development normally takes place at the day centre. More emphasis should be placed on this area identifying the things service users enjoy doing independently, and creating these opportunities within the residential setting. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 15 A variety of meals are on offer. Service users said they could choose what they wanted and particularly enjoyed the food. A record of food consumed is maintained showing that meals are generally well balanced and nutritious. Stocks of food were seen to be plentiful, with a variety of fresh and frozen produce. Staff and service users said that they often do shopping locally for the items they want. This is nice as it indicates a good deal of flexibility. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have personal support in the way they prefer and require. Health care is well planned, which ensures service users needs are consistently well met. Medication is generally well managed, which ensures service users get the right medication at the right time. EVIDENCE: Nevin House accommodates service users who have a range of different personal and health care needs. Some people have specific health care needs relating to the ageing process, and varying degrees of learning disability and associated needs including; Epilepsy, mental health, or mobility. Routines are flexible and seen to meet the needs of service users, each has a plan showing their particular routine and level of support needed, this ensures that those who require it have the structure they need and that personal care is met in a manner that is appropriate to their individual preferences, particularly where service users cannot easily communicate this. Service users confirmed that arrangements for clothes buying, and appearance were to his liking and that staff supported him in this area. This means service users are supported in having the choices about their appearance that are similar to their peers and reflective of their age, personality and gender. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 17 Service users’ general attire and appearance was a good indicator that they receive a good standard of basic personal care. It was noted that from care plans that service users are supported to access primary and specialist healthcare in accordance with their needs. The care plans contained specific interventions relating to individual health care needs. These specified the signs and symptoms to look for and the type and level of support staff should offer the service user. It was evident staff had good knowledge of the health needs of service users. It was positive to see that the accommodation offered to a service user with decreased mobility was in line with his needs. The bathing facilities currently meet the service users needs; a hoist chair ensures the service user can be transferred safely into the bath. Daily records show that health care and potential complications are monitored, and dealt with. Staff had good information regarding the management of Epilepsy, and awareness of how to support mental health care. There is good monitoring of the side affects of medication, and ensuring that fluid intake is monitored. These arrangements ensure that any change in the condition of the service user is picked up quickly and referred to the G.P. Medication management was generally good. A record of medication received, administered and returned had been maintained. The audit of medication was accurate, and the security safe. The manager carries out in-house audits of medication to ensure procedures are followed and mistakes rectified, this is good practice and ensures the safe administration of medicines to service users. Some service users spoken with had good information as to their health care needs to include the reasons why they were on medication, and what it was for. They were happy with the support they had. One service user said, ‘Staff support me to make G.P. appointments’. One service user is supported to part manage his medication within a risk management framework. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The Complaints procedure has been given a good profile ensuring service users know how to raise concerns. Service users finances are managed well, ensuring they are protected and have access to their money. There are arrangements to protect service users from abuse. The arrangements for protecting service users from self-harm need to be more robust. EVIDENCE: The Commission has not received any complaints with regards to this service. The service users said they were aware of how to make a complaint. Copies of the complaints procedure are made available to service users in a format suited to their specific needs this was seen and is in print and pictorial format. Service users said that they could talk to the manager and other staff about anything that concerned them and were confident that their concerns would be listened to, and acted upon. The three men described lots of occasions when they sat with staff and discussed all sorts of events that would affect them, it was positive to see that staff use these spontaneous occasions to promote a good understanding of safety issues. All complaints are recorded in the complaints log book, and this is reviewed and followed up by the manager, ensuring that complaints are investigated and the outcome fed back to the service user. The service has a policy and procedure for the protection of adults. This follows the multi agency guidelines published by Birmingham Social Care & Health. Staff training records showed that staff have received training in this area, team meeting minutes demonstrate that procedures are discussed and Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 19 reviewed to ensure staff know the procedures for protecting vulnerable service users. Care plans show that a procedure is in place to minimise the likelihood of selfharm. Risk assessments are detailed and support the action staff should take. It was disappointing to see that staff failed to follow these procedures and more concerning, this incident was brought to light by the inspector sampling records, therefore the manager had not been aware that an incident had taken place. This raises concerns in how well these incidents are reported for follow up. A number of months have passed since the incident, which could potentially have compromised the safety of the service user. This was discussed at length with the manager. An Immediate Requirement was made to ensure that this incident is reviewed and appropriate action taken to ensure that staff follows procedures necessary to the safety of service users. The Commission has not been notified via Regulation 37 of incidents and accidents within the home, and this must also be improved. The arrangements for safeguarding service users finances are mainly managed by staff. Appropriate records are maintained, and banking arrangements are in place. Service users report that they have access to their money as they wish, and one service user confirmed he has his own bankcard. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is appropriate to their current lifestyle and needs, as well as being homely, clean and comfortable. Some redecoration is required to ensure service users continue to enjoy the benefits of a well maintained home. EVIDENCE: Nevin House is a domestic scale semi-detached house, which has been extended and improved for the benefit of the service users. 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 service users showed the inspector around their home, bedrooms were individually furnished and personal possessions were evident. One bedroom is situated on the ground floor, which is appropriate to the current mobility needs of the service user. The ground floor bathroom has a hoist to meet the needs of the service users, but is in need of some redecoration. An upstairs shower offers further bathing facilities. These facilities are not spacious but currently meet the needs of the service users without difficulty. However as the long-term needs of service Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 21 users change, the need for assisted bathing facilities will need to be considered. The lounge and conservatory provides a space where service users can engage in quieter pursuits such as board games, meet visitors in private, or choose to spend time away from the main group. There is a programme of redecoration. Some areas of the house are showing signs of wear and tear; peeling paper in bedrooms, and the bathroom. The carpet is lifting at the entrance to the first floor bedroom, potentially causing a trip hazard. The manager said that they are hoping to create a maintenance post so that some of the minor repairs and redecoration can be carried out this will enhance the comfort of service users. Service users said they are satisfied with their accommodation they have adequate storage and shelving. Service users were happy with their rooms, having DVD’s videos and music centres to enjoy. Two of the three rooms reflected personal space individual to the service user, in terms of their age and interests. One bedroom had bedding not in keeping with the gender and age of the service user, the manager said she did not know why this bedding was on his bed, but would follow it up. Service users had a lockable facility in which to keep their medication. Cleanliness standards were good; the house was warm and tidy. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent staff supports service users. Planned refresher training will ensure the needs of the service users continue to be well met. EVIDENCE: The annual training schedule showed that three of the care staff has obtained their NVQ level 2 and that two are currently doing level 3, one has commenced level 4. The manager advised that she has obtained her Registered Managers Award and is waiting to complete NVQ level 4 in care. A staff training and development plan was required at the last inspection, and this was seen to include, (for each member of staff) details of all training completed and qualifications gained to date. Refresher training is highlighted and the plan also showed when outstanding training is scheduled, much of this is planned for 2007 and includes Fist aid, food hygiene, infection control, manual handling, health and safety, fire safety and medication. 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. Staff Induction is based on the Learning Disability Award Framework (LDAF), designed for staff in the social care setting. This covers all aspects and Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 23 principles of care for those working with service users who have a learning disability, it includes all the statutory training staff requires, to do their job effectively. It was previously recommended that the use of a simple checklist could improve the management and filing of recruitment information. The manager has implemented this system and a checklist was available to show that all the necessary documents and checks are in place to safeguard the service user, ensuring that recruitment practices are robust. Since the last inspection the manager has ensured that all members of staff have received formal supervision. Each member of staff now requires an individual training needs assessment and plan to ensure future planning is linked to meeting the needs of the service user. The manager advised that the first round of staff appraisals is planned for May 2007. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run with, with positive outcomes for service users. However more robust reporting procedures need to be in place to ensure the wellbeing of service users. 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. Her management style has been described by previous reports, and comments from staff and service users, as open and inclusive. She is involved in the day-to-day operation of the service within the home. There have been some incidents within the home that highlight the need for more robust communication between the staff and the manager. This was discussed with the manager and an Immediate Requirement was made to this effect. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 25 The service users have known the manager for a considerable time and say they can raise any matters of concern directly with her, and are comfortable in doing so. The manager advised that she has purchased a formal quality assurance system. Some progress has been made in developing a quality assurance system that takes on board all the service users’, relatives’/carers’, and staff’ view points about the service offered. This is managed via service user meetings, and staff meetings. Involvement of relatives and external professionals is limited. There are also systems now in place that enable the manager to carry out audits, and monitoring of practice areas. This has included environmental audits, safety checks, medication audits, and records checks. The manager has also conducted spot checks to ensure staff are carrying out their duties responsibly. This is particularly important given that staff work alone for some of the shift. It was positive to see that where shortfalls have been identified, the manager has taken immediate steps to rectify these. The results of the outcome of these checks need to be published and made available to service users and other parties so that they have a formal means of measuring achievements. It may be useful to consider a newsletter to keep people updated on the service achievements. There are good arrangements to ensure the health and safety of service users and staff. Records sampled showed that the servicing and maintenance of equipment had been undertaken as required. Records were looked at during the fieldwork and found to be in a good order. Legionella checks were completed annually. There was a Gas Landlord Certificate in place, ensuring the gas supply was safe. Fire safety procedures are consistently carried out; emergency lighting is checked monthly, fire drills and weekly tests are undertaken. It was noted that the fire risk assessment is due for review in April. The outcome of this must be developed into a suitable emergency action plan showing the control measures in place to ensure fire safety. Sampling of incident and accident records indicated some inconsistencies in reporting to the Commission, as per the requirements of regulation 37. There had been some falls, and some incidents relating to ‘risk’ that had not been reported. All incidents or accidents that adversely affect the wellbeing of the service user, must be reported to ensure their safety. This was discussed with the manager who gave an undertaking to review the current arrangements and ensure that regulation 37 requirements are met. This will ensure that any situation that may compromise the safety of the service user is known, recorded and acted upon. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 26 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 3 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 27 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) This is a previous requirement. Procedures must be followed consistently to minimise risks to the safety of service users. This is an Immediate requirement. Ensure that care plans actively support service users to take risks as part of an independent lifestyle. Service users should be actively supported to plan, prepare and cook meals. The care plan must state how they will be supported in this area, or the reasons that they cannot undertake these opportunities. The reporting of ‘risk’ incidents to the manager must be improved. Delays could potentially place service users at risk. This is an immediate DS0000017051.V326984.R01.S.doc Timescale for action 31/05/07 2. YA9 13(4) (a) & 18 (1) (a) 12(4) (b) 11/04/07 3. YA9 31/05/07 4. YA17 15 (1) 30/04/07 5. YA23 23 (4e) 11/04/07 Nevin House Version 5.2 Page 28 requirement. 6. YA24 23(2) (d) A programme of redecoration is required. Some areas of the house are showing signs of wear and tear; *Peeling paper in bedrooms. *Peeling paper in the bathroom. The carpet is lifting at the entrance to the first floor bedroom, potentially causing a trip hazard. This must be secured/made safe. Bedding must be appropriate to the needs of the service user. Each member of staff requires an individual training and development plan. Confirmation of completion of NVQ level 4 in care should be sent to the Commission. The outcome of the fire risk assessment must be developed into a suitable emergency action plan showing the control measures in place to ensure fire safety. The registered person shall give notice to the Commission without delay of the occurrence of any event in the home, which adversely affects the wellbeing or safety, of any service user. Specifically falls, incidents and accidents. 30/04/07 7. YA26 16 (2) (c) 11/04/07 8 9 10 11 YA26 YA35 YA37 YA42 16 (2) (c) 18 (1) (C))(i) 10 (3) 23 (4) (e) 11/03/07 01/05/07 31/05/07 30/04/07 12. YA42 37 (1) (e) 11/04/07 Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 29 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 YA27 YA39 Good Practice Recommendations Seek to incorporate person-centred approaches into future care planning, in keeping with the aspirations of Valuing People. It is recommended that the long-term needs of service users, are kept under review in terms of assisted bathing facilities. A system for publishing the results of service user surveys to service users, their representatives and other interested parties including the Commission, should be considered. It may be useful to look at a news letter presented in a suitable format to meet the needs of service users. Nevin House DS0000017051.V326984.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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