Inspection on 03/03/08 for The Old Coach House

This inspection was carried out on 3rd March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Coach House 05/01/07

The Old Coach House 24/11/05

The Old Coach House 12/05/05

The Old Coach House 10/02/05

The Old Coach House 22/09/04

The Old Coach House 29/03/04

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 28/09/2008.

CARE HOME ADULTS 18-65 Old Coach House 20 Wychall Park Grove Kings Norton Birmingham West Midlands B38 8AQ Lead Inspector Lesley Beadsworth Unannounced Inspection 3rd March 2008 02:00 Old Coach House DS0000016807.V360666.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 Old Coach House DS0000016807.V360666.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. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Coach House Address 20 Wychall Park Grove Kings Norton Birmingham West Midlands B38 8AQ 0121 451 2779/1433 F/P 0121 451 1433 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Old Coach House DS0000016807.V360666.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 5th January 2007 Brief Description of the Service: The Old Coach House is a spacious, detached house along a drive between houses in a residential area of Kings Norton. There are shops nearby and reasonable access to public transport. Accommodation is provided for up to five adults with dual sensory impairment and additional learning disabilities. All the bedrooms are single. Two of the bedrooms are on the ground floor and three are on the first floor. There is no lift. There are two bathrooms one on the ground floor and one on the first floor. Both are domestic in style and have no aids or adaptations. There are two additional toilets on the ground floor. An office is available on the first floor of the house. The home has a large lounge with a separate large dining area. The garage has been converted into additional communal space and used as a sensory/activity room. The premises are adequate in size and furnished/equipped to a good standard. There is a secluded garden to the rear of the property that is much used in the summer months and has a range of good seating facilities. The costs of living at the home is not included in the Service User Guide but contains an explanation that fees are dependent on individual assessment and are negotiated with the funding authority. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection included a visit to The Old Coach House. As part of the inspection process the registered manager of the home completed and returned an Annual Quality Assurance Assessment (AQAA), which is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service. Information contained within this, from previous reports and any other information received about the home has been used in assessing actions taken by the home to meet the care standards. Two residents were ‘case tracked’. This involves establishing an individual’s experience of living in the care home by meeting or observing them, talking to their families (where possible) about their experiences, looking at resident’s care files and focusing on outcomes. Additional care records were viewed where issues relating to a resident’s care needed to be confirmed. Other records examined during this inspection included, care files, staff recruitment, training, social activities, staff duty rotas, health and safety and medication records. The inspection process also consisted of a review of policies and procedures, discussions with the manager, staff, visitors and residents. The inspection visit took place between 2pm and 10pm. The Assistant General Manager was present throughout the visit. What the service does well: People who live at The Old Coach House are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed, which are recorded in good detail, prior to admission which enables the home to know if it is able to meet their needs or not. Potential residents have several opportunities to visit the home and to interact with other residents before moving into the home. Detailed and person centred care plans are developed that are devised with the residents’ involvement and which are reviewed regularly and revised as necessary when circumstances change. Care plans also included any necessary information related to the gender of the person caring for the resident. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 6 Each resident has a weekly activity schedule which they had been involved in drawing up. Activities included ice-skating, horse riding, indoor rock climbing, shopping and eating out. The activity plans varied each week so that had the opportunity to do different things they wished to do. Means of communication with the people living at the home, all of whom had double sensory loss and learning disabilities, were also included in the care plan and a ‘trouble shooter’ diagram showed staff exactly how to ensure the person received the most effective use from their hearing aid. Each resident had access to the community and had a weekly activity programme, which they had been involved in drawing up. The activity schedules were varied and were based on the preferences of the individuals. Observations made, discussion with staff and records looked at made it clear that people living at the home have the opportunity to make choices in their daily lives, such as when to get up and go to bed, what to eat, whether to join in activities or not and where to spend their time. The privacy of each person living at the home is respected. For example a switch outside each bedroom is used by anyone about to enter the bedroom of a resident. This turns on a ceiling fan in the bedroom, which alerts the occupant that someone is about to enter their room. It was evident that health was being monitored effectively and that health care services were being received according to their individual needs. The home has a comprehensive medication policy. The medication systems safeguard the residents’ health and well being. The home has appropriate policies, procedures and training in place to safeguard the people living at the home. The physical design and layout of the home enables people who use the service to live in safe, well maintained, and comfortable surroundings both inside and outdoors. The home has a minibus that is available to the residents each day and is used by them for trips and outings. The people who use the service are supported by a trained staff team and are safeguarded by the homes recruitment procedures. There are sufficient staff to meet the needs of the people living at the home. Staff were seen to interact well with the residents and treat them respectfully. All observations and discussion indicated that staff cared for residents in a respectful manner. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 7 Staff were receiving supervision at appropriate intervals and records were available to support this. There is an organisational Quality Assurance programme in place and a representative of the registered provider visits unannounced each month to monitor the services offered. A report of this visit is forwarded to the manager and to us. These systems indicate that the home is monitoring the service in order to enable growth and improvement. A random check on health and safety records indicated that the home was a safe place to live and to work. What has improved since the last inspection? All requirements from the previous inspection had been met. Detailed risk assessments were in place for all areas of daily living, showing that they are supported in taking reasonable risks to maintain their independence. These had been reviewed monthly. Although not relevant to the people who were case tracked the AQAA advised that where choice is restricted this is included in the care plans with appropriate risk assessments. The Statement of Purpose had been updated. All residents had an up to date care plan that was reviewed regularly. Detailed risk assessments were in place for all areas of daily living, showing that they are supported in taking reasonable risks to maintain their independence. These had been reviewed regularly. All people living at the home had contact with their family and the home made arrangements to support one person to visit their family at their home. Residents were weighed regularly and links had been made with the dietician for support when there were concerns about weight loss. The home had developed good protocols for PRN (as required) medications. The majority of the staff had undertaken medication training and only those who had been trained were responsible for administering medication. The complaints procedure had been given to all residents and was available in different formats. The paving slabs in the rear garden had been levelled thereby reducing the risk to residents. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 8 All documentation required for staff were in place in order to safeguard residents from the appointment of unsuitable employees. All staff had undertaken mandatory training in order to make the home a safe place to live and to work. Fire training and drills were up to date. The sensory room had been developed and steps made safer. The décor of the home had been made brighter to assist a resident with some vision to get about the home more easily. The office had been moved downstairs providing better management oversight during the day. 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. The summary of this inspection report can be made available in other formats on request. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 9 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 Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 10 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): 1,2,4, Quality in this outcome area is excellent. People who live at The Old Coach House are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed prior to admission which enables the home to know if it is able to meet their needs or not. Prospective residents make visits to the home and meet other residents prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which had been updated since the last inspection. However the manager has since left the home and this therefore needs amending in the document. Sense (the registered providers) make the Service User Guide available in different formats to make the document more accessible to people who live in the home. There were no vacancies for residents at the time of the visit. When a referral is made to the home the needs of each prospective resident are assessed by the manager and the referrals officer in order to establish whether the home is able to meet these needs or not. The prospective resident then has a minimum of three visits to the home, at different times of the day, meeting other people living there and assessing their interaction before making a decision about Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 11 moving in. The pre admission assessments looked at were recorded on a comprehensive format and were in good detail. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 12 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 & 9 Quality in this outcome area is excellent. Staff are provided with detailed information to ensure residents’ assessed needs are met. The people who live at the home are supported to make decisions and are enabled to take reasonable risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are developed from the Person Centred Plan that the core teams produce with the resident. The home also has a link Practice Development Worker (PDW) who supports the staff team with the development of residents’ care plans and risk assessments. The care files of two residents were looked at and each contained well detailed information regarding the care. A brief summary in the care file leads staff to the relevant sections of the care plan where there was detailed information about how staff should support people to meet their needs, explaining clearly not only what care was needed but where and how. They were reviewed Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 13 regularly and revised as circumstances changed. Care plans also included any necessary information related to the gender of the person caring for the resident. Detailed risk assessments were in place for all areas of daily living, showing that they are supported in taking reasonable risks to maintain their independence. These had been reviewed regularly. Although not relevant to the people who were case tracked the AQAA advised that where choice is restricted this is included in the care plans with appropriate risk assessments. Means of communication with the people living at the home, all of whom had double sensory loss and learning disabilities, were also included in the care plan and a ‘trouble shooter’ diagram showed staff exactly how to ensure the person received the most effective use from their hearing aid. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16 & 17 Quality in this outcome area is good. People who use the service are able to make choices about their life style, and supported to develop their life skills and their independence is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident had access to the community and had a weekly activity programme, which they had been involved in drawing up. Activities included ice-skating, horse riding, indoor rock climbing, shopping and eating out. The activity plans varied each week so that had the opportunity to do different things they wished to do. Each activity had a risk assessment in order to remove any avoidable risks. Special occasions such as birthdays were celebrated. Daily records showed the days events including what activities had been taken up and the responses to these activities. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 15 Each person’s activity schedule also includes a session related to developing domestic skills, such as dusting, vacuuming and bed changing. The home’s garage had been converted into a sensory room, which was equipped with light panels and other light arrangements, a stereo system and beanbags and other equipment of sensory importance. The room was said by the staff and the manager to be well used by the people living at the home, although was not seen in use during the visit. The home had a minibus for the residents’ use and which they contributed 60 of the mobility part of their benefits. The vehicle is available for their outings and trips and is used every day, enhancing the day-to-day lives of the residents. Observations made, discussion with staff and records looked at made it clear that people living at the home have the opportunity to make choices in their daily lives, such as when to get up and go to bed, what to eat, whether to join in activities or not and where to spend their time. Contact with family and friends was maintained and the organisation’s family liaison officer supported staff at the home to do this, especially with families that lived some distance away or were having difficulty in travelling to the home. Contact is also maintained by phone. At the time of the visit arrangements were being made to organise for one resident to visit their family. Menus were available and showed that a varied and nutritious diet is provided that meets peoples’ needs and preferences and which is changed weekly. Snacks such as fruit, crisps and yoghurts were also available each day. On the evening of the visit the people living and working in the home were enjoying a take-way meal, as there had been an electrical power cut in the afternoon preventing the cooking of the evening meal. The Assistant General Manager of the organisation advised that the home maintained good links with the dietician and any diet concerns, for example weight loss, in the home could be referred to them. The privacy of each person living at the home is respected. For example a switch outside each bedroom is used by anyone about to enter the bedroom of a resident. This turns on a ceiling fan in the bedroom, which alerts the occupant that someone is about to enter their room. Old Coach House DS0000016807.V360666.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& 21 Quality in this outcome area is good. Service users are supported to maintain their personal care in accordance with their preferences and with attention to their privacy and dignity. Service users receive regular health screening and action is taken in response to identified changes in health. This helps service users to stay as healthy as possible and gives them the best opportunity to recover from any ill health. The medication system safeguards the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care plans were looked at as part of the case tracking process. People who live at the Old Coach House have a range of healthcare needs and from the records observed it was evident that health was being monitored effectively and that health care services were being received according to their individual needs. A dentist visits every six months and a chiropodist every six to eight weeks. The home has an appointed continence advisor who visit the home regularly and reviews for individual needs. The GP surgery is close by and the Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 17 AQAA reports that the residents have built good relationships with the GPs. This evidence shows that residents on going health care needs were being met. Care plans were clear about the way in which the person wished to be cared for and discussion with the Assistant General Manager, staff and observations made indicated that these wishes were respected. All personal care and any medical or nursing care were carried out in the privacy of the resident’s own room. Although the suggested time for people living at the home to get up is before 09:30am there was a flexible approach to this, dependent on the resident’s commitments for the day, and if people wanted to stay in bed they were able to do so. Going to bed and mealtimes are also flexible. The home does not use the key worker system but a core of staff are allocated to each resident who are responsible for the Person Centred Process from which the individual care plan is developed. The team is responsible for liaising with the person’s family, friends and other people involved with their support; for organising monthly core team meetings; for supporting the person to prepare their own information regarding the process of person centred planning. The home has a comprehensive medication policy. The responsibility of administering medication is that of the shift coordinator, that is the person in charge of the shift. That person retains the medication keys which is a safe practice. Medication is stored in a secure cupboard although there is no locked medication fridge. Any medication needing to be kept refrigerated is stored in a locked box in the main fridge. The organisation should consider purchasing a suitably lockable fridge. A recent pharmacy inspection did not identify any problems and the home was satisfied with the service they received from their designated pharmacist. Only staff who have undertaken medication training are allowed to administer medication. This was confirmed in discussion with staff. Medication Administration Record Sheets were looked at and no unexplained gaps or incorrectly used codes were seen. Staff carried out a tablet audit at every handover in order to check that the correct medication had been given. A random audit of some of the medication was carried out at the visit and all were correct. The home had a very good protocol regarding PRN (as required) medication. Copies of prescriptions were kept so that medication received is checked against them. Records are kept of medication received and disposed of on the Medication Administration Record Sheets. Some instructions had been handwritten on the Medication Administration Record Sheets. To ensure the accuracy of these two people should sign the entry and indicate where the Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 18 instructions had come from. Other than this the medication system safeguarded the health and welfare of the people living at the home. When a resident passed away due to cancer, diagnosed through routine health checks at the home the bereaved persons were supported. The Assistant General manager was able to describe the way in which the end of life care and the eventual loss was managed by working with the family, residents and staff team. Counselling was made available for staff and anyone who had a close relationship with the late resident. A memory book had also been devised to which bereaved persons can refer. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 19 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. People who use the service and their representatives are given the opportunity to express their concerns and have access to an effective complaints procedure. Appropriate procedures are in place to safeguard service users from potential abuse. There have been no incidents or allegations of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and visitors have access to the complaints procedure and a copy is included in the home’s Statement of Purpose. The organisation provides this in a variety of formats for residents, family and visitors. Each resident had a copy provided on their admission to the home. This includes stages and timescales of the procedure, stating that there will be a response “preferably within 14 days and certainly no longer than 28 days”. If there is no satisfaction the complainant is able to contact a Complaints Receiving Officer on a Freephone number. There had been no complaints made since the last inspection. There is a record book in which complaints or concerns are logged Appropriate policies were in place for Protection of Vulnerable Adults. Staff had attended appropriate training in order that they were able to identify abuse and to protect residents from abuse. Staff have also had ‘protection questionnaires to complete to focus them in order to refresh their knowledge. There is also a flowchart available to staff that directs them in what to do if there is an allegation or suspicion of abuse. There had been no adult protection referrals made since the last inspection. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 20 Some monies were held on behalf of people living at the home. Records were examined and were in good order with appropriate receipts. A random check of cash balances was made and these tallied with record made. The indications were that the home’s practices protected the residents’ financial interests. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 21 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): 24,25,27,28 &30 Quality in this outcome area is good. The physical design and layout of the home enables people who use the service to live in a safe, well maintained, and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers safe, well-maintained, clean and comfortable indoor and outdoor surroundings that are free of any offensive odour. The home lies back from the other houses on the road and is approached via a narrow alleyway between two other houses. There is a small car park, which accommodates the home’s minibus. A wall separating the car park from the neighbour’s garden was in disrepair. Although this was the responsibility of the neighbour the organisation was prepared to share the costs to speed up the repair. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 22 There is a secluded rear garden with suitable seating and is apparently used a great deal in good weather. A summerhouse in the garden was being used for storage during the winter months but which is popular with the residents in the summer. Slabs had been levelled since the last inspection to reduce the risk to residents. The décor of the home had been made brighter since the last inspection to assist one resident with some vision to find their way about the home better. The entrance of the home leads to a large, attractive and comfortably furnished lounge with ample seating for the people living and working at the home. An adjoining dining area was appropriately furnished and a large dining table accommodates all residents and the staff who would support them through the mealtime. All bedrooms were viewed, were of single occupation and had personal and tactile signage at each door to enable the sensory impaired residents to be able to identify their room. Each bedroom had been personalised, mainly with items of sensory importance such as scatter cushions of different textures. To inform the occupant that someone is about to enter the room staff press a timed switch that turns on a fan in the bedroom. Some residents had a folding massage table in their bedroom for their personal use. Whilst each bedroom had a washbasin in order to meet the required standard staff advised that the residents do not use them. There was a bathroom on the ground and first floors with new easy to clean wall covering. Both were clean and hygienic and both had a curtained shower cubicle. The kitchen had been recently refitted and was clean and in good order. All containers used by residents had a suitable recognition object attached, for example the sugar container had a spoon; the coffee jar had a coffee granule surface; a cup was on a cupboard storing cups. These objects assisted residents to recognise where things were and supported them in their independence. There is a small laundry area adjacent to the kitchen which residents are also encouraged to use. This was clean in and in good order. Since the last inspection the office and sleep-in room had been changed around so that the office was on the ground floor giving better oversight and contact with the residents and the sleep-in room was on the first floor. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 23 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. The people who use the service are supported by a trained staff team and are safeguarded by the homes recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen to interact well with the residents and treat them respectfully. All observations and discussion indicated that staff cared for residents in a respectful manner. Care plans advised how best to communicate with the people living at the home who all had dual sensory impairment and additional learning disabilities. Staff had undertaken a variety of relevant training to support the people living at the home. Training records were provided and showed that staff had undertaken the mandatory training of moving and handling, health and safety, food hygiene, first aid and fire safety. They had also undertaken further training including that related to medication, infection control, communication, adult protection, challenging behaviour and a support worker workshop. Four staff had also attended a course on sexuality and relationships. Other training Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 24 not included in the training records but which staff files looked at showed had been undertaken included, ‘Working Together with Deafblind People’ and ‘Nonviolent Crisis Intervention’. Staff have the opportunity to undertake National Vocational Qualification training after their six-month probationary period. Three members of the care staff/support workers, that is 33 , have achieved National Vocational Qualification Level 3, which means that they have been assessed to be competent in their role. The required ratio is 50 and the home should be working towards achieving this. The Assistant General Manager said that there were three members of staff on each shift to support the five people living at the home, which there were on the day of the visit, and this was also shown on the rotas looked at. In line with the organisation’s gender sensitive policy, when rotas are planned care is taken to ensure a balance of gender and confirmation that there is had been recorded on rotas. The home has needed to use agency staff at recent times but ensures that the same people are used in order to maintain continuity of care. a profile of each agency staff member used is kept at the home to ensure that they are adequately trained, and experienced and have had the appropriate checks requested. The home has a robust recruitment system that protects the people living at the home from unsuitable staff being employed. All stages of the recruitment are verified and well recorded. There was evidence of the appropriate checks having been carried out. One Staff file did not contain a copy of a Criminal Records Bureau check but there was evidence to show that this had been received. Further enquiries made by the Assistant General Manager discovered that the previous registered manager had destroyed the copy as is suggested by the Criminal Records Bureau but had kept a record of the disclosure number and date. We are therefore confident that the appropriate checks had been made for this member of staff. Staff were receiving supervision at appropriate intervals and records were available to support this. Staff supervision is necessary as it allows the management to meet with staff on a one to one basis to discuss practice, personal development and philosophy of the home issues. It is also an opportunity for staff to contribute to the way that the service is delivered. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 25 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 and 42 Quality in this outcome area is good. Whilst there is not a registered manager in post the service is effectively managed, and the home is well run. Residents’ views are sought and influence the way the service is delivered. The home is a safe place to live and work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous registered manager had resigned last year and the deputy manager was on maternity leave. The Assistant General Manager of the organisation was managing the home in the absence of a designated manager and the process of recruiting to the post was in place. The deputy manager returned to work before this report was completed and a part time acting manager was appointed until the manager post is filled. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 26 The home had a Quality Assurance Programme in place, which included internal and external audits to obtain feedback from all people connected to the home. An action plan had been developed based on the outcome of the feedback. A representative of the registered provider makes monthly unannounced visits and a report is made on this visit with copies sent to them of the home and to us. These systems indicate that the home is monitoring the service in order to enable growth and improvement. Staff meetings were held monthly to give staff an opportunity to give their opinions of the service and to affect the way the service is delivered and how it can be improved. Residents too are encouraged to give their opinions A random check was made on health and safety records. Fire safety checks were up to date and staff had undertaken fire safety training. Staff had also undertaken moving and handling training. Temperatures of hot water that can be accessed by residents were monitored in order to prevent any accidental scalding. There were no substances hazardous to health (COSHH) items accessible to residents. The home presented as a safe place to live and work. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 X 3 X X 3 X Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 28 No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA1 YA20 Good Practice Recommendations The Statement of Purpose should be updated to show the changes in management. All handwritten instructions on Medication Administration Record Sheets should be countersigned by a second person. Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Old Coach House DS0000016807.V360666.R01.S.doc Version 5.2 Page 30 - 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. 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