Inspection on 13/12/05 for Nicholl Grange

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nicholl Grange 18/12/06

Nicholl Grange 14/12/04

Nicholl Grange 08/04/04

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

CARE HOME ADULTS 18-65 Nicholl Grange Nicholl Grange 14 - 22 Nicholl Street West Bromwich West Midlands B70 6HW Lead Inspector Mike Kirton Unannounced Inspection 09:30 13 December 2005 th Nicholl Grange DS0000004820.V263156.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 Nicholl Grange DS0000004820.V263156.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. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nicholl Grange Address Nicholl Grange 14 - 22 Nicholl Street West Bromwich West Midlands B70 6HW 0121 525 3828 0121 525 3828 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) Sandwell Association for Mental Health Jephson Housing Association Limited Heidi Whapples Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: Nicholl Grange is an independent sector home that provides residential accommodation, including four self-contained flats, for up to fourteen people experiencing mental ill health. The home’s main objective is to provide a supportive environment in which to enable residents to live independently within a community setting. Support is provided with all aspects of daily living skills with a focus on individual needs and maintaining good mental heath. The home is situated close to West Bromwich town centre with easy access to all local amenities and transport networks. Parking is available at the front and there are extensive well-maintained gardens at the rear. The ground floor consists of an entrance hall, office, 2 single bedrooms, laundry room, small lounge, dining room, kitchen, main lounge (where smoking is permitted), storage cupboard and two separate toilets. Two staircases lead to the first floor, which includes two toilets with walk in showers, toilet and bath, a kitchenette, staff bedroom and eight single bedrooms. A further four registered places are provided in an adjacent building with self-contained facilities. Sandwell MIND has responsibility for both the management and staffing of the home whilst Jephson Housing Association is responsible for the maintenance of the building. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 hours and included a tour of the buildings, and informal interviews with 4 staff members and 3 service users. Health and safety records and 2 individual care plan files were examined. What the service does well: What has improved since the last inspection? 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. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 6 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 Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 7 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: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 6th July 2005. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 8 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 6th July 2005. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 9 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: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 6th July 2005. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 10 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 The home has good systems in place to enable service users to live as independently as possible whilst ensuring their personal and medical care needs are met. Generally the administration of medication procedures are satisfactory however some improvements are required. EVIDENCE: The care plan records for 2 service users were examined. These contained detailed information on how they are to receive their personal care. Residents were observed to be making their own decisions on how to live their lives such as when to get up or whether they wanted to go out. Assistance was seen to be provided by the care staff as needed. Feedback received from service users and staff was very positive. They felt the home allowed them to develop skills for living independently and were happy with the level of support provided. Comprehensive records were also being maintained to ensure that all medical needs were being met and monitored. All appointments are entered into the homes diary and transferred to a daily activities sheet. Outcomes are noted on a log sheet for chiropody, optician, dental appointments etc. (as identified in their care plan and/or assessment). A separate log is maintained for GP and psychiatric outpatient appointments. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 11 The homes policy and procedure (available on the Sandwell MIND’s website) for medication was signed by staff responsible for administration to ensure that it had been read and understood. Following a risk assessment service users can either have their medication manager by staff or start a staged programme towards self-administration. The medication files were examined and found to contain all the required information including service users photograph, list of medications, and what they are prescribed for. There was also additional guidance provided by medical professionals when needed. Some errors were identified including several gaps in the record sheet where no entry had been made yet the drugs were not in their container. Some medication was also missing from a blister pack, which was not yet due for dispensing. This had already been identified by staff and investigations were being made. Risk assessments had not been updated. Additionally not all staff responsible for administering had been on a recognised training course. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 12 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 Nichol Grange has good procedures in place to ensure that service users are protected from abuse. They also welcome feedback on how well their service is being received and involve users in any decision making which will affect them. EVIDENCE: The homes complaints procedure was clearly displayed in reception and contained all the required information including contact details for the Commission. Other notices included an advocacy service, user involvement, MINDS conferences, minutes from in house meetings, statement of purpose, and service users guide. There is also a collection box available for written feedback. MIND has a policy and procedure relating to adult protection and whistle blowing (available on their website), which is dated and reviewed. Staff have signed to confirm that this has been read and have also received training. The home also has a copy of the social services procedures. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 6th July 2005. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 14 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, 33, 34, 35 Nichol Grange has good recruitment and selection procedures in place to ensure that service users safety is protected. All staff met during the inspection demonstrated professional skills, a comprehensive knowledge of the service users needs, and were more then able to fulfil their roles. The home however must ensure all mandatory training is provided. EVIDENCE: The home is now fully staffed. In addition to the manager there is a shift leader and 3 care workers on duty during the day and 2 care staff during the night (1 awake and 1 sleep-in). From Monday to Friday there is also a cook (12:00 to 18:00) and domestic (9:30 to 13:30) on duty. This was accurately reflected on the duty roster. This inspection was unannounced and the manager was not present to allow access to staff files. On previous inspection however rigorous recruitment procedures were followed in line with legal requirements and Sandwell MIND’s policies. Discussions with 3 staff members recently appointed confirmed that they had been through a selection process and did not start work until a police record check and 2 satisfactory references had been received. They had all undergone or are completing a 6-week induction programme (a copy is available on their web site) followed by a 6-month foundation-training programme. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 15 Feedback received from staff was very positive about the home and the way in which it is run. They all felt supported by the manager and received regular supervision. There was evidence that not all mandatory training was being provided. As previously recorded not all staff responsible for administering medication had been on a recognised course. An acting shift leader was still completing their foundation course and had not yet enrolled on a NVQ level 2 in care. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 16 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): 39, 32 The home continues to be managed well and recent improvements to the decoration and furnishing have been carried out. Good systems are in place to ensure the health and safety of service users, staff, and other visitors to the home are protected. EVIDENCE: Nichol Grange has systems in place to receive feedback from service users, visitors, and others people who come into contact with the home. This along with other relevant information required for an effective quality assurance and monitoring system must be published on an annual basis with an action plan for any improvements. A tour of the buildings communal areas showed that the home was clean and tidy and well maintained. New flooring was being laid and many areas had been redecorated. Several items of furniture do need replacing including the seating in the main lounge. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 17 The fridge, freezer, cooked food, and water temperatures were being recorded and monitored. Servicing of the fire equipment, gas, electrics, and portable electrical appliances was been undertaken. Fire evacuations were being carried out, a fire risk assessment was in place, and the alarms were tested every week. Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 18 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 X X X X Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Nicholl Grange Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000004820.V263156.R01.S.doc Version 5.0 Page 19 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 YA3 Regulation 12 Requirement Alternative placements must be sought for service users whoose primary need is not covered by the current conditions of registration. The medication records sheet must be completed accurately. The cause for the missing medication must be identified. Risk assessments for service users must be updated. All staff responsible for administering medication must complete a recognised training course. All staff must undertake the minimum required training as identified in their individual plan. The home must publish the results of their quality assurance monitoring system on a annual basis and implement an action plan to improve service delivery. Timescale for action 01/04/06 2 YA20 13 01/01/06 3 4 YA32 YA39 18,19 17,24,26 01/04/06 01/04/06 Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Nicholl Grange DS0000004820.V263156.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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