Inspection on 18/07/06 for The Pines (Birmingham) Ltd

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines (Birmingham) Ltd 25/04/07

The Pines (Birmingham) Ltd 07/02/06

The Pines (Birmingham) Ltd 23/08/05

The Pines (Birmingham) Ltd 02/03/05

The Pines (Birmingham) Ltd 07/07/04

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

CARE HOME ADULTS 18-65 Pines,The (Birmingham) Ltd 29 Bishopton Close Shirley Solihull West Midlands B90 4AH Lead Inspector Joe O’Connor Unannounced Key Inspection 18th July 2006 10:15 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pines,The (Birmingham) Ltd Address 29 Bishopton Close Shirley Solihull West Midlands B90 4AH 0121 744 3945 0121 7443945 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) Care Through The Millennium Mrs Mary Teresa Read Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care may be provided to people, subject to appropriate assessment, who have both a learning disability and a mental disorder. Date of last inspection 7th February 2006 Brief Description of the Service: The Pines is a detached property located in the Shirley area of Solihull in a quiet residential area. It is close to local bus routes for Solihull, Hall Green, Kings Heath and Birmingham City Centre. The service is also in close proximity to local amenities including the GP surgery, library, Shirley shopping centre and places of worship. It provides a permanent accommodation for service users with a learning disability who may have also complex needs including challenging behaviours and mental illness. The accommodation comprises on the ground floor a spacious lounge with kitchen and separate dining room. There are two ground floor bedrooms one with en-suite shower facilities. The other bedroom has a dedicated bathroom. An office is located on the ground floor that is also used as a sleep in room. There is a separate laundry area with an activity room as part of a conversion of the garage. There are four bedrooms on the first floor of which three have shower facilities. There is a large well maintained garden with a patio area and there is some off road parking. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over one day with a follow up visit made during the morning 20 July 2006 to sample staff recruitment records and talk to the Registered Manager. The Inspector spoke to two service users and two members of staff including the deputy manager. Comments were also received from service users, staff and relatives on CSCI surveys following this inspection. Service users care records were examined along with risk assessments. Care practices were also observed. Health and safety records were also inspected. Additional information was also examined in what is known as a pre-inspection questionnaire that is sent out to the home before the fieldwork visit, along with a history of the service including significant events. To compare how the service has performed since the last inspection then this report should be read with the previous unannounced inspection report 7 February 2006. There was no information available regarding the weekly fee for the service. What the service does well: The people live in a building where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home isn’t known. People were receiving friendly and professional support from the care staff during this inspection. The atmosphere was relaxed and friendly. One of the service user’s was celebrating his birthday and had lots of presents and cards. He was going out later that afternoon with his friends who live in the home for a birthday meal. Two people provided comments about what it was like where they were living. One said, “It is much better here since the last manager left and the new manager makes sure staff do what they are supposed to do”. Another said, “I like living here and get on well with all of the staff”. Some comments were received from relatives who had completed CSCI survey forms. One stated she thought staff were welcoming and always kept her informed about her daughter’s appointments. Another commented their brother was well looked after. People are able to provide comments to a representative of the organisation about the care and support they are receiving. The representative visits every month and writes a report after their visit, which is available for inspection. Staff are also able to provide comments as well. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Some improvements are needed in ensuring each person’s care plan has complete information as to how they should be supported during the night. The review of the care plan must say whether there have been any changes or none at all. It is important that all manual handling assessments have been reviewed ensuring they are clear in saying how people should be supported and moved. People should be given the opportunity to cook meals of their choice, which should be part of promoting their independence. The minutes for the monthly meetings must show what action is being taken to follow any requests for alternative meals and activities. They must also indicate what progress had been made since the last meeting. People should be consulted first before staff are allowed to access their debit card PIN numbers. Any decision must be recorded on their care plan in consultation with their social worker. This is to protect both the people living in the home and Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 7 staff when they are handling their money. Staff must have training in understanding epilepsy. Not all staff have had training in adult protection and manual handling. The manager must make sure that for future inspections the staff records are always available for inspection. The organisation could think about letting the manager have a team of bank staff so that there is always someone to cover shifts when someone is off sick or on holiday. Each person’s care plan must be clear about if care and support should be provided by a male or female member of staff. Parts of the building need to be decorated including some of the window frames where the paint is peeling off. The carpet in the hall is badly marked and worn. One person said the television set in the lounge isn’t big enough for every one to be able to see clearly. 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. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 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 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Standard 2 not assessed Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users have information about the service, which must now be reviewed and amended to include the fees charged by the service. Service users needs are currently met which are now being reviewed through appropriate professional support. EVIDENCE: The service has as a statement of purpose and service user guide, which is set out in a written format. Each service user has a copy of the service user guide. Recent amendments in the Care Homes Regulations 2001 from 1 July 2006 mean that the service user guide must contain information about the fees charged by the service. Both sets of documentation should be reviewed annually. The service user guide is currently available in a written format but consideration must be given in developing it in a more accessible format such as symbol/photographs for those service users who cannot read. Since the last inspection the Registered Manager had left the service and it was not known why she had left. A new manager has been in post since April this year. A sample of three service users’ care records indicated she was undertaking reviews of their needs through a referral to a Community Nurse. All but one of the service users had recently been reviewed by Birmingham Social Care & Health to determine their continued suitability for residential Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 10 care. However, the assessments completed by the Social Workers had not been left on the service users’ file. One service user file sampled found there was regular contact and consultation being made with a Clinical Psychologist in working with staff to assist the individual in reducing moments of anxiety and aggression. The service has had no new admissions since the last inspection. The atmosphere during this inspection was relaxed and friendly. Two service users gave their views about the support they were receiving. One service user said “Everything is fine it is much better since the last manager left ”. Another said, “I like living here and get on well with all the staff”. Three CSCI relatives’ surveys received following this inspection was positive about the support being provided by the home. One of the comments stated in particular, “ I am welcomed by staff and they let me know if there are any problems and about any appointments for my daughter”. Another commented, “They look after my brother well”. Three comments were received from staff who thought that what they did well was in ensuring the service users were well cared for and they are able to do what they want, although one commented there could be more staff when shifts needed covering. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users are encouraged to make their decisions about their lives through service users meetings but the minutes for these must show what actions have been taken and these have been evaluated at the next meeting. Care plans while detailed must be clear in stating how service users should be supported during the night. Service users have risk assessments in place to state how any risks should be minimised in the home and when in the community. EVIDENCE: Three service users care records were sampled during this inspection. Each service user had a care plan that included information about their daily routines including their preferred term of address and when they got up or go to bed. While the care plans were detailed about how the service users needs were being met there were some discrepancy in how they should be supported at during the night. One service user’s care plan stated he did not wish to have checks during the night but the individual’s daily recording indicated staff were undertaking checks at night. Another care plan referred to the service user Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 12 being incontinent during the night but it did not say how the service user was to be supported to manage this and the type of continence pad to be used. The care plans had been reviewed but there must be additional information to say whether there have been any changes or not and not just the date of review. Since the last inspection the new manager has introduced Me and My Life booklets as part of making the care plans more person centred. Each service user had a risk assessment, which referred to how service users were to be supported in the home and when out in the community. One risk assessment viewed had more information about how the service user should be supported when going out watch his football team and how many staff were required. There were also risk assessments in place for another service user and how staff should respond to any changes in behaviour. These were completed alongside detailed guidelines developed by a Clinical Psychologist who was also involved in recent reviews and expressed satisfaction to staff with the progress being made by the service user who was having fewer outbursts. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users are able to access social and leisure activities in the community independently or with support from staff. Service users are encouraged to maintain contact with family members and there are good relationships with staff. There are no unnecessary restrictions on service users daily routines. Service users do not have the opportunity to prepare their own meals as part of developing their independence. EVIDENCE: At the time of this inspection two service users had gone out to Birmingham Industrial Therapy Association, which is a specialist employment service. One of the service users who works there said he enjoyed working in their shop and is paid £20:00 per week. Another service user was due to go to her day service provided by the Local Authority. However, the service user was unable to go because of staff sickness that day, but in any case had to attend an emergency GP appointment following a fall the previous evening, which resulted in her Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 14 right elbow being bruised. The service user did go out later during the afternoon for a pub lunch with two service users one of who was celebrating their birthday. The service user who was celebrating his birthday was being encouraged by staff to indicate what he would like to do for his birthday. It was good to see staff giving him presents and sing happy birthday. The service user supports Birmingham City and had recently purchased a new season ticket. The service user had also bought a licence for fishing. The deputy manager on duty stated the service user enjoys this and they are hoping to pursue this activity on a regular basis. An examination of service users’ daily records indicated staff were recording how they were spending their leisure time in the home and when out. The service users had been involved in a number of activities including visits to the cinema, pub lunches, bowling, Lickey Hills and Cannon Hill Park. The service users had recently been out to a beer and skittles night in Wythall and also had been to Shirley Carnival. The service does provide a holiday for all of the service users. Two had been on holiday to Spain this year. At the time of this inspection a member of staff was arranging for one of the service users to have a long weekend in London later this year. Observations indicated there were no unnecessary restrictions placed on service users and there was evidence confirming they were being offered a key to their bedroom. A sample of service users care plans referred to the service users’ daily routines. One referred to the service user having a lie in every Friday until 10:00am and that he had his own coffee making facilities in his bedroom. While another stated they always got up at their preferred time of 5:30am and enjoyed going shopping. Two service users said they maintained contact with their relatives during the week. One spends time with he mother every weekend and goes to church with her. She also calls her mother every week. Another service user also has home leave at the weekend had recently obtained a free travel pass. Observations at the time of this inspection found there appeared to be a good relationship between the service users and staff. Two service users were asked about the meals provided during the week. Another service user commented that he is able to cook but did not have an opportunity to do this, despite requesting to this in the service users meetings. There was some indication that the service users were able to discuss menu choices in the meetings but not every month. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 15 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 Quality outcome in this area is adequate. Service users receive support with personal care but their care plans must state their preferred gender in providing support. Service users access community and specialist healthcare services independently or with support from staff. Medication management requires some minor improvements to promote and maintain service users’ good health. EVIDENCE: Observations at the time of this inspection indicated the service users were well presented and dressed appropriately for the climate of the day. The current group of service users are made up of five white male service users and one white female. Staff support is provided mainly by white females with two white male care staff so there is reasonable gender care support. The care plans however, do not refer to service users’ gender care preferences. Two service users commented they were able to get up and go to bed when they wanted to. One of the service users was having a lie in at the time of this visit, as it was his birthday. A sample of three service users’ daily records referred to where they had received support with their personal care and when they had a bath or shower. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 16 Each service user has a manual handling assessment but two seen had not been reviewed since December 2005. One of the service users’ care records sampled had an incomplete nutritional assessment in despite the fact the service user had specific eating and drinking guidelines completed by a Speech and Language Assessment. Another nutritional screening tool had not been reviewed since November 2004. A record of weight for one of the service user’s found this was being maintained every month while another service user was being weighed at his GP. There was documented evidence seen confirming when service users had seen healthcare professionals such as GP, Dentist, Optician and Chiropodist. One service user said he attended his own GP appointments and managed his own medication. Additional evidence seen also confirmed a number of service users had access to specialist healthcare services including medication reviews with a Consultant Psychiatrist. One of the service users has regular support from a Clinical Psychologist. A referral had been made for one of the service users to receive input from a Physiotherapist in March this year but there was no evidence stating the outcome of the referral and the manager said she would follow this up. The same service user had been seen by an Occupational Therapist to assess his needs with regard to prevent him from falling out of his bed. The manager has introduced a yearly OK Health Check plan, which refers to service users healthcare requirements and the professionals involved in their support. It was suggested to the deputy manager on duty that these would benefit in making these more personalised with the use of photographs of who provides the support and where they have to go. Medication management was to an acceptable standard. An examination of the Medicines Administration Records indicated there were no gaps in recording and when sampling medication in boxes there were no discrepancies in the remaining balances. There were photocopies of prescriptions attached to the MAR sheets and there were protocols in place for the use of PRN medication. It was noted however that homely remedy authorisations for each service users were in need of review. The pre –inspection questionnaire stated two members of staff had completed accredited medication training. The service had received a visit from the supplying pharmacist a month before this inspection who did a medication audit. The audit identified some improvements in ensuring staff enter quantities on MAR sheet from previous month to new sheet and keep only one white blister pack for PRN medication. A risk assessment to determine on of the service user’s competency to self medicate was not signed or dated. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 17 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 Quality outcome in this area is adequate. Service users concerns or complaints are responded to appropriately by the organisation. Some safeguards are required in ensuring service users bank accounts are secure and protect their interests. EVIDENCE: The service has received three complaints since the last inspection. These were made by a service user who had complained about the behaviour of another service user. A written response had been made to each of these complaints by the previous manager. The complaints had been entered on to the home’s complaint record. Each service user has a copy of the complaints procedure as part of their service user guide. Two service users spoken with said they would be able to go to the manager if they were unhappy with the support they were receiving. One comment received from a service user following this inspection stated that only sometimes staff would listen and act on what he said. An examination of staff training records indicated all but two members of staff had completed training in adult protection. There is a copy of the latest adult protection multi agency guidelines published by Birmingham Social Care & Health. The majority of staff had received training in physical intervention. An examination of two service users’ personal expenditure records found that generally these were being managed well. However, it was noted a receipt for a trip out to a stately home had not been entered on one of the service user’s personal record. Each service user has their own bank account with a debit card. Details of the service users’ individual PIN numbers were written down Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 18 and there was no evidence confirming whether service users were consulted about this. Service users’ monies were held in individual containers and stored securely. The manager had made an adult protection referral regarding one of the service users when a service user raised concerns that a member of his family was trying to access his financial records. There were clear recorded evidence as to the action taken by the manager and contacts she had with the social worker who recently attended a review and was due to attend another meeting following this inspection. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users liven in a clean, tidy environment but some improvements are needed. EVIDENCE: The premises was generally clean and tidy at the time of this visit. Since the last inspection one of the service users had improvements made to his en-suite shower facility to make it more accessible for his mobility needs. The deputy manager stated there was a problem in that the shower needed a gate to stop the water from running out into the bedroom. The manager must ensure this is addressed. When touring the premises it was evident the paintwork outside of the building was peeling and in need of re-decorating. A number of bedroom window frames were found to have their paintwork peeling. One of the service user’s bedrooms was in need of re-decorating and there was a crack in the ceiling. One of the windows in the lounge was found not to be closing properly. The deputy manager commented that much of the décor in the premises could do with being re-painted as most of it has remained the same since the service Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 20 first opened in 1998. The floor covering in the laundry area was found to be peeling away. The carpet in the hallway was found to be in need of a thorough clean. The CSCI will require a plan of future refurbishment and decoration of the premises for the current financial year. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 21 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 Quality outcome in this area is good. The organisation offers and provides training for all staff enhancing their development but specialist training in epilepsy is required. Service users are supported by adequate numbers of staff on duty. Staff recruitment records generally meet the requirements of the regulations with minor improvements needed. EVIDENCE: The pre-inspection questionnaire stated that out of nine members of care staff employed in the service, six were working towards or had qualified to NVQ Level 2 or above. This is a little over 50 of its workforce. This was also confirmed when examining the staff training records. Two members of staff had commenced training towards NVQ level 3 in May this year. The deputy manager commenced training towards the Registered Manager Award. One member of staff had registered for training towards the Learning Disability Award Framework while one staff member interviewed stated she was halfway through her LDAF training. At the time of this inspection one member of staff had called in sick but the deputy manager on duty had managed to arrange cover for the shift. She commented there had been some problems recently with staff sickness, which has left them short at times. Two new members of staff had commenced Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 22 employment since the last inspection. The new manager did comment that she would like a team of bank staff so that any shortfalls in shifts can be covered. She would be discussing this issue with the Registered Provider. An examination of the staff rotas for the previous four weeks indicted appropriate levels of staff were being maintained. Comments received from two members of staff who had sent in CSCI staff surveys commented there were usually adequate numbers of staff on duty as opposed to always. The Registered Provider should give consideration to the use of bank staff in order to any gaps on the rota. An examination of staff training records most staff had completed mandatory training in areas such as first aid, food hygiene and manual handling. It was noted however not all staff had completed training in manual handling, challenging behaviour and risk assessing. There was also gaps on the training records indicating only one staff member had completed training in infection control. There are two service users who have epilepsy and it was noted none of the care staff had received training in this area, which must be addressed. The manager stated she was investigating a suitable training package for person centred planning. Two staff recruitment records examined found one had all the required documentation such as job application form, interview assessment form, two references, CRB check, proof of identity including a photograph. Another file seen only had one reference. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users will need stability while a new manager is in post. Service users live in an open relaxed, friendly atmosphere, which they appreciate. Service users are able to comment about the service they receive every month to a representative from the organisation. Service users records must be audited, as some of the information is old which does not clearly reflect their individual circumstances. Service users health and safety is promoted to a good standard protecting their interests. EVIDENCE: The Registered Manager had left the service since the last inspection. A new manager has been in post for four months and she was completing an application to be Registered Manager. However, the manager did advise that she will have to take time off in October due for medical treatment and the CSCI will need to be advised of the managerial arrangement for the service Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 24 while she is absent. The new manager has had a wide experience of working with people who have learning disabilities in a residential healthcare setting and is a qualified learning disabilities nurse. The manager had yet to register for the Registered Managers Award. In discussion with the manager she has identified areas where staff must improve practice such as following guidelines drawn up by professionals and the recording of information on the care records. There have been issues around staff relationships, which the manager feels are getting better. Two service users spoken with said they liked the new manager and would be able to approach her if there were any problems. One of the service users commented what he liked about the new manager was the way she made sure staff did what they were supposed to which was not always the case when the previous manager was in charge. Two members of staff said they found the new manager approachable and supportive. One thought the service users had taken to her well and there was a better atmosphere. Comments received from a member of staff who completed a CSCI staff survey did feel communication between staff could be better as there would be confusion as to what service users were doing during the day. There could be more efficient use of the communication and staff handover book. Staff meetings occur every month and minutes were seen for these. A representative from the organisation visits the service every month and there were written reports of their visits. There was evidence confirming the representative had spoken to service users and staff about the management of the service. Service users had completed quality audit questionnaires and there was reference to the service users being asked if they wished to have a key to their bedroom. It was noted satisfaction surveys for staff had not been completed since August 2005, while those for the relatives were completed in December 2005. The manager must ensure a new round of surveys are completed as part of its quality audit. At the time of this inspection it was not possible to access the staff recruitment records which necessitated a further visit to view these. The deputy manager stated that she did not have a key, which was held by the manager who was on annual leave during this visit. The Registered Person must ensure all records are available for inspection at any time as set out in Section 31 Care Standards Act 2000. Some of the care records were in need of updating and review with some information over three years old. Records with regard to health and safety were satisfactory. There was evidence confirming the fire alarms were being tested every week and the emergency lighting every month. A fire drill had occurred prior to this inspection. Records for the inspection and testing of fire fighting, gas and electrical equipment were also up to date. Staff had received fire safety training since the last inspection. There was a risk assessment in place for the prevention of fire. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 25 An examination of the accident book indicated six had occurred since the previous inspection. All had been reported to the CSCI via Regulation 37 notification. Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 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 2 2 N/A 3 3 4 N/A 5 N/A 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 N/A 26 N/A 27 N/A 28 N/A 29 3 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 2 35 2 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 N/A LIFESTYLES Standard No Score 11 N/A 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 N/A 2 3 3 N/A 2 3 N/A Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(a)(b) (c) (2) Sch 1 5(1)(b) Requirement The Registered Person must ensure that the Statement of Purpose and Service User Guide are reviewed to include information about the fees charged by the service. Consideration must be given in developing the service user guide in a more accessible format. The Registered Person must ensure service users’ care plans are clear in stating how service users should be supported during the night and how their continence needs should also be managed at night. The care plans must show more evidence of service users’ involvement in their development and review. The Registered Person must ensure that the minutes for the service users; meetings state action to be taken when any requests for activities or changes to menus have been made. Timescale for action 18/10/06 2. YA6 15(1)(2) 18/10/06 3. YA8 12(2)(3) 16(2)(i) 18/09/06 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 28 4. YA17 5. YA18 The Registered Person must ensure service users are given the opportunity to prepare their own meals 12(2)(3)(4) The Registered Person must (a)(b) ensure service users’ gender 13(5) care preferences are recorded on the care plans. Manual handling assessments must be reviewed. 12(1)(a)(b) The Registered Person must ensure all nutritional assessments are reviewed and updated 13(2) The Registered Person must ensure risk assessments for people self medication are signed and dated 13(6) 12(2)(3) 18/09/06 18/09/06 6. YA19 18/09/06 7. YA20 18/09/06 8. YA23 9. YA24 23(2)(b) The Registered Person must 18/09/06 ensure written protocols are in place to ensure the reasons why staff are accessing service users PIN numbers and what steps are being taken to protect their interests. The Registered Person must 19/09/06 ensure it provides the CSCI a plan with timescales of future refurbishment and decoration, evidencing how the premises will be maintained to a safe and presentable standard. The floor covering in the laundry area must be repaired. 10. YA34 19(1)(b)(i) 17(2) Sch 2 The Registered Person must ensure two references are obtained during the recruitment process 18/09/06 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 29 11. YA35 18(2) The Registered Person must ensure all staff undertakes training in epilepsy awareness, infection control and adult protection. The Registered Person must ensure staff recruitment records are made available for inspection. An audit must be undertaken ensuring old care records are archived. The Registered Person must ensure it develops a fire procedure in a suitable and accessible format. Outstanding Requirement. Timescale 7 April 2006 not met. The Registered Person must ensure the manager makes application to register with CSCI. 18/09/06 12. YA41 13. YA42 31(1) (3)(a) (4)(a) Part II Care Standards Act 2000 17(2) 13(4) 23(4)(e) 18/09/06 18/09/06 14. YA37 9(1) 18/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that the Registered Person gives consideration in developing service users care plans in a more person centred format with copies given for each service user. It is recommended that the Registered Person supports service users to access local advocacy services if they wish to discuss any concerns in private. It is recommended that the Registered Person provide opportunities for service users to have activities indoors when they don’t go out. 2. YA8 3. YA14 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 30 4. YA19 It is recommended that the Registered Person develop individual health action plans in line with the Department of Health Guidelines Valuing People. It is recommended that the Registered Person develop the complaints procedure in a suitable pictorial format. 5. YA22 Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pines,The (Birmingham) Ltd DS0000004514.V290528.R01.S.doc Version 5.1 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!