Inspection on 25/04/07 for The Pines (Birmingham) Ltd

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines (Birmingham) Ltd 18/07/06

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 Martin Brown Key Unannounced Inspection 25th April 2007 10:30 Pines,The (Birmingham) Ltd DS0000004514.V335066.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 Pines,The (Birmingham) Ltd DS0000004514.V335066.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. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pines,The (Birmingham) Ltd Address 29 Bishopton Close Shirley Solihull West Midlands B90 4AH 0121 744 3945 F/P 0121 744 3945 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.V335066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care may be provided to people, subject to appropriate assessment, who have both a learning disability and a mental disorder. That Mary Teresa Read undertakes a recognised accredited training programme in physical intervention by 30th September 2005. 18th July 2006 Date of last inspection 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. Current fees are £1,250 per person per week. This does not include hairdressing, toiletries, magazines or the cost of leisure activities after 5pm. It also includes up to £300 towards the cost of an annual holiday. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 10.30 on a weekday morning and lasted for six hours. All residents were present for at least some part of the inspection. Records were examined, a sample of service users were ‘case tracked’, that is, their experience if the service looked at in detail. The manager, staff and residents spoken with, and interaction between residents and staff was observed. All at the home were welcoming and helpful. Prior to the inspection, completed questionnaires had been received from four of the residents, in most cases filled in with assistance from staff. These were generally positive, and issues raised in them by residents were discussed with the residents concerned, and feature in this report. A survey form was also received from one relative, which was very positive concerning the service. The Pre-Inspection Questionnaire for the home, completed and returned by the acting manager, also informed the inspection. What the service does well: What has improved since the last inspection? The service has worked hard to address concerns and shortcomings identified in the last inspection, with improvements in recording and procedures. Positive progress was noted in the well-being of residents, with an improvement in mobility and a reduction in recorded falls noted. Similarly, consultation with outside professionals has resulted in clearer practice in supporting those with swallowing difficulties, resulting in less recorded incidence of choking. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 6 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. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment procedure involves opportunity for the service to become familiar with prospective residents in order to ascertain whether it can meet their needs. Prospective residents may benefit from a clearer, more simplified ‘Service User Guide.’ EVIDENCE: The home currently has one vacancy. A resident informed me that a new person was ‘moving in’. The manager advised that one person had visited for tea, and that an initial assessment had been done as regards suitability. This had not been done by the manager, and contained some details, but was not yet complete. For example, it contained details concerning previously observed behaviours, but nothing on their frequency, severity, or how they are managed. The manager advised that the assessment was still in the early stages, and agreed that the assessment needed to be thorough, especially as the vacancy had arisen following the breakdown of a previous placement. All those living at the home have individual contracts, detailing fees. The Statement of Purpose and Service User Guide was seen. The Service User Guide is not yet in a more ‘service user friendly’ format. The manager emphasised that prospective residents gain information more readily about the service from extended visits to the home. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their assessed and changing needs are reflected in their individual plans, and that they are supported to make choices and to take risks. Some residents may benefit from information concerning their lives being available to them in more accessible formats. Residents may not always be in full agreement with aspects of their care plans. EVIDENCE: Discussions with residents, and observations of interactions, showed that residents are supported to make everyday decisions about their lives, with staff observed to offering choices in respect of meal and drinks and drinks and activities. The main limitation was where residents required staff assistance in outside activities and wanted to do something that had not been planned for. In this instance, a wish to walk to the local park and play football could not be immediately met owing to other demands on staff time. The resident accepted this, and was prepared to wait. Discussion with the resident and staff, and looking at daily recordings, showed that this activity was a frequently practised one. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 10 Care plans showed that guidelines in respect of care needs and particular areas of risk are in place and are regular reviewed. Signatures on care plans showed service user involvement in the formulation and review of care plans. Discussion with residents demonstrated some awareness of care plans, but it was evident that whilst care plans may be a means to an end, they held little interest for residents in themselves. One resident, although able to understand the concept of his care plan, showed very little interest in it. Care plan folders contain certain information in a user-friendly format, showing aims, likes and dislikes clearly, but these are within bulky folders containing much other information, a lot of it in a less accessible format. The acting manager agreed that separate ‘life history’ or similar, books, with simple statements of likes, dislikes, needs, and activities, and well-illustrated with photographs, might be of use and appreciated by some residents, although it was agreed that they might not be appropriate for everyone. One stated aim on a care plan was for a resident to give up smoking. Whilst he may have agreed to this plan at the point of discussion, it was far from clear that this was a realistic, or wholly wished-for aim on his part. Records show that regular service user meetings take place. Residents showed an awareness of these, with one commenting “We talk about holidays, and what we’re having to eat”. Minutes from the most recent meeting were pinned to the wall, unfortunately in type too small to easily read, and pinned on top of the fire alarm and complaints procedures. The manager agreed to reconsider the whole issue of how to best convey such information as fire procedures, complaints, and service user meetings in a way that best met the varying needs of the people living in the home. Residents spoken to on these topics showed a good awareness of fire procedures, which appeared to have been conveyed by reminders from staff, rather than attention to notices. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a variety of activities that they enjoy, and that caters for a wide variety of individual interests. The service caters for a wide variety of needs in terms of people being supported to exercise rights and responsibilities. Residents enjoy a healthy diet that caters for individual choices. EVIDENCE: The residents had all returned the previous day from enjoying a ‘long weekend’ holiday in Cornwall. During the inspection, there was a lot of coming and going. One resident had a lie-in, going out to the shops when he finally got up. Another returned form a hospital appointment later in the day, whilst a third was supported by staff in getting a new fishing licence in readiness for the new season. One resident returned from his employment later in the day, and was keen to tell me of his work. One resident was happy to tell me of regular family contacts and visits, and of forthcoming activities. Residents were familiar with local facilities, most notably the shops, park, pubs and restaurants. Residents have a variety of interests; one enjoys fishing and Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 12 watching his favourite football club. Another enjoys playing football. Staff support these activities. Another resident said he disliked most activities, unless they involved food or music. The kitchen was well-stocked and clean, menus showed a variety of nutritious food being available, and reflecting residents’ choices. Snacks during the day reflected residents’ choices, and support was given by staff as necessary, with some preparing their own snacks unsupervised, whist others were closely supervised throughout the meal, in accordance with the management of assessment risks, such as choking. One person who is able to cook, having done various cooking and food preparation courses at his local college, is now able to cook for himself. He stated that he would like to cook a meal for others in the home. A discussion followed that agreed that there should be no problem with this if other residents were happy with this and that a thorough risk assessment showed that it could be done safely. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in ways they prefer and need, and have their health needs met. The shortcomings noted in the administration and recording of medication are in the context of an otherwise good provision of personal and healthcare support. Residents can be confident that the manager will address isolated shortfalls in the administration and recording of medication, and will promote their wellbeing in respect of what medications they are prescribed. EVIDENCE: The manager was able to show, with reference to the rota, how there are always female staff available to assist the female resident with any personal care. Where falls, seizures, and swallowing/choking were particular hazards, care plans, observation, and discussion with staff management and residents demonstrated that these were now being managed appropriately. Outside support, such as speech and language therapists, had been involved in minimising choking risks and risk assessments and guidelines had helped minimise risks from falls and seizures. Observation showed staff offering choice Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 14 and properly prepared food and support where swallowing was a particular issue. The manager advised that falls, which had been a concern for one resident previously were not occurring now. The route to the two ground floor bedrooms involves a small step. The manager agreed that advice might usefully be sought from an outside professional as to whether a handrail of some sort might be useful to install by the step. Medication records were examined. Each person’s Medication Administration Record Sheets is preceded by a photograph of the person and details of individual medications and their reason, and possible contra-indications. One instance was found of medication not being signed as given, when its absence from the medi-dose indicated that it had. In the same pack, one tablet was found in the previous week’s medi-dose, although the foil had been opened, indicating that although that container had been ‘popped’ the member of staff had not noticed that this tablet had remained in place. The manager agreed that this was not satisfactory and was to raise the matter with the individual staff member and with all staff, to consider whether refresher training in medication administration is needed, and to instigate daily checks to ensure that this does not happen again. This was an isolated incident; all other medication was consequently checked and found to be satisfactory. Where medication is not done via the medi-dose system, a check on a sample of tablets showed that dispensing was fully recorded and that numbers recorded tallied with those remaining. Several residents are receiving relatively large number of medications. Two residents appeared quite tired in the middle of the day. One resident acknowledged that he frequently struggled to get up in the morning. The manager advised that medications are frequently reviewed with the relevant professionals, but agreed that she would make additional effort to promote the possibility of any safe reduction in medications. Details of how and why certain medications, such as topical creams, are taken are in individual care plans, but not in the medication records. The manager agreed that it could be beneficial to have these in the individual medication records, to be more accessible to staff dispensing this medication. There was nothing in the medication records to indicate whether individual residents had any allergies that might be relevant to medication. The manager agreed to rectify this, and advised that, although residents were not known to have allergies to such as penicillin, one resident had recently had a medicine stopped after showing an adverse reaction to it. She is aware of the need to record this information for future reference, and in the case of no known allergies, for this to be recorded. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 15 One resident self-medicates, with support and monitoring from staff, and with regularly reviewed risk assessments in place. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their views are heeded, and that the service works well to protect them from abuse, neglect, and self-harm. The service strives to maintain the rights of residents whilst encouraging individuals in a less harmful lifestyle. EVIDENCE: The complaints log was looked at. There was only one complaint, which concerned a complaint by one resident against another, which had been resolved. Observations in the home showed residents’ views being listened to and acted upon, and pre-agreed activities being carried out. Records of residents’ personal monies were seen. These showed finances were being managed appropriately. There is now an improved protocol in place for staff to support residents in using their cash cards. Not withstanding this, the manager agreed that, to further guarantee safe practice at all times, she would ensure that cards are separately locked away and only accessed by a member of staff who signs to acknowledge responsibility for that card whilst it is not locked away. Staff spoken to showed a good awareness of abuse and what to do if it was suspected or witnessed. A programme is in place to encourage one person to get out of bed earlier. This, and attempts to encourage him to smoke less and eat less and exercise more, has potential to bring him into conflict with the service. He had mentioned during a previous inspection ‘not getting on’ with staff, and on this occasion mentioned that a member of staff could be ‘bad tempered’. The acting manager agreed that any programme aimed at improving his well-being had to Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 17 be managed very carefully, and with appropriate outside professional support, which it has. She acknowledged that for any programme to work, it had to be managed consistently and professionally, and would ensure that staff worked with residents courteously at all times. This was the case throughout the inspection, where there was no indication that staff interacted with residents in anything other than a warm, courteous, patient and professional manner. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a homely, comfortable and well-maintained environment. Addressing areas noted will further enhance this. EVIDENCE: The home was clean, well furnished and decorated on this inspection. Painters had done some decoration whilst residents were on holiday; similarly, the large hedging surrounding much of the garden had been cut. The garden is accessible, spacious and well-maintained, able to accommodate one person’s liking to play football, as well as flowers and a place of relaxation for others. Residents were content for me to be shown their bedrooms, but none wished to do so themselves. Bedrooms are well maintained, and contain personal possessions and pictures. One very clearly demonstrates one gentleman’s footballing loyalties. One person has a key for his bedroom. The manager advised that others are happy to leave theirs open. This appeared to be the case from observation and discussion. One shower does not fully work, delivering only a dribble of water. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 19 Communal areas were comfortable and safe, with two potential exceptions. in the kitchen area, a mat was starting to curl at one corner. The manager acknowledged that this needed replacing. There is a small, carpeted step leading to the downstairs bedrooms. The manager agreed that a hand rail may be of benefit here for residents, and would have this assessed. She advised that she was unaware of it presenting difficulties to the current residents. The laundry floor has been resurfaced/repainted in line with a previous requirement. The home was clean and hygienic throughout during this unannounced inspection. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by a consistent and properly recruited staff team. More staff training in mental health needs would help support for those with such needs. EVIDENCE: Rotas and observation during the inspection demonstrated a sufficient deployment of staff to meet residents’ needs. The service avoids the use of agency and other staff unfamiliar with and to residents, relying on a existing staff to provide a consistent staffing regime with whom the residents appeared secure and comfortable. A sample of staff files were examined. These were amongst the more recent recruits, and records showed that appropriate procedures and checks are being followed, including Criminal Record Bureau and Protection Of Vulnerable Adults checks, and two written references. Induction, training and supervision of staff takes place as required. Individual staff issues such as timekeeping were being addressed. Staff spoken to were able to demonstrate a good awareness of issues such as fire safety, ‘whistleblowing’, and individual residents’ needs, and were Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 21 observed to interact with residents in a relaxed and friendly manner throughout. The manager advised that training for staff is progressing, with all staff except the two most recent recruits having completed National Vocational Qualification level 2, and with 3 staff completing or having completed level 3. The revised induction package was seen, and appeared to be a thorough grounding and a good preparation for the job and for future learning. Details of mandatory and service-specific training was detailed on the pre-inspection questionnaire. The home is registered to provide care for people who have a mental disorder, as well as a learning disability. Staff currently have little specific training in this area, and those spoken to on this subject agreed that they may benefit from such training in understanding and supporting any residents with such needs. The manager agreed that training in awareness of mental health issues would help give staff greater insights into the management of any service user with mental health needs. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from a well-run home that promotes the health, well-being and safety of those living there. The acting manager has worked well to address previously noted deficits and residents will hopefully continue to benefit from consistent management. EVIDENCE: The acting manager advised that she is nearing completion of the Registered Manager’s Award, and expected to have completed this by July 2007. She has applied with the Commission for Social Care Inspection to be the Registered Manager, and is aware that, the certificate on display in the home must be amended to reflect the changes. The acting manager has worked well to meet shortfalls identified at the previous inspections, with decoration in the home being evident, and updating of care plans taking place and the meeting of care needs taking place. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 23 There was evidence of surveys and questionnaires of residents and relatives to find out if people are happy with the service. The manager’s own quality assurance process identified areas for improvement and consequent action, as exampled by work on the garden. Regulation 26 visits by the registered person take place as evidenced by reports. The manager showed interest in the idea of home managers within the organisation taking part in such quality assurance visits on homes run by other managers. Information provided on the pre-inspection questionnaire, discussion with the manager and staff, and observations in the home showed health and safe practices and checks to be satisfactory. Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 24 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 3 4 3 5 3 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 2 25 3 26 3 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 3 x Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13(2) Requirement The registered person must ensure that all medication is administered and recorded accurately. Details of whether or not individuals have any allergies are to be recorded in medication records. The mat in the dining room is a potential tripping hazard and must be replaced. The en-suite shower that is currently not properly working must be made good. The service must have a suitably qualified registered manager. The registration certificate must accurately reflect this. Timescale for action 01/05/07 2. YA20 13(2) 01/06/07 3. YA24 23(1) 01/05/07 4. YA27 23(1) 01/06/07 5. YA37 9(2) 01/08/07 Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA6 YA8 Good Practice Recommendations The Service User Guide should be available in a more ‘service user friendly’ format. ‘Life History’ books or similar, may be of benefit to some residents. The service should reconsider the best way of conveying information such as fire procedures, complaints procedures, and service user meetings, to those living in the home. Advice should be sought regarding the benefit or otherwise installing any support by the carpeted ground floor step Details of how and why medications are taken should be recorded on individual medication sheets, as well as individual care plans. Mental health training would better assist staff in supporting any residents with mental health needs. 4. 5. 6. YA18 YA20 YA35 Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pines,The (Birmingham) Ltd DS0000004514.V335066.R01.S.doc Version 5.2 Page 28 - 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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