Inspection on 07/02/06 for The Pines (Birmingham) Ltd

This inspection was carried out on 7th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Pines (Birmingham) Ltd 25/04/07

The Pines (Birmingham) Ltd 18/07/06

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 The Pines (Birmingham) Ltd 29 Bishopton Close Shirley Solihull West Midlands B90 4AH Lead Inspector Joe O’Connor Unannounced Inspection 7th February 2006 11:00 Pines,The (Birmingham) Ltd DS0000004514.V281621.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.V281621.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.V281621.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.V281621.R01.S.doc Version 5.1 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. 23 August 2005 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. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over a day with assistance being provided by Stephen Ellis who is known as an Expert by Experience and his supporter Dawn Owen from Sandwell People First Organisation. They spoke with three service users and spoke to one of the staff members on duty. Service users care records were examined including care plans and risk assessments. A number of health and safety records were also sampled. Observations of care practices were also undertaken. The Inspector spoke to the Registered Manager. For an overview as to how the service has performed during this inspection year then the report should be read with the announced inspection report 23 August 2005. What the service does well: Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as care home isn’t known. The expert by experience thought that the building was clean, tidy and well decorated. Service users were observed to receive friendly and professional support from staff. The expert by experience thought the staff communicated well with the service users. They were dressed in clothing that reflected their age and climate for the day. The expert by experience commented that overall he felt it was a positive visit. He was particularly pleased that the service users were given three choices of a main meal and liked the fact they can choose on a daily basis and although the food menu is written for the week it was flexible. Three service users spoke with the expert by experience and commented about what it was like in the home. One service user stated she liked the staff and also liked the manager. Another service user said he was able to go out by himself without staff support and enjoyed watching war films. One service user was particularly excited about going to a Carling Cup football match involving Birmingham City later that evening. He also told the expert by experience about his birthday party that happened the day before which involved his relatives. The expert by experience was pleased that the service users are taken out and not just left indoors, because they are doing things in the community. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: While the expert by experience was pleased that the service users had three choices of main meals during the day he thought the menus could be developed in a more accessible format. He also thought that the service users should have an easy to understand complaints procedures. It was good that the manager had made improvements to the content of the written care plans for the service users, the expert by experience commented the service users should have their own accessible copy that is individual to them in an understandable person centred format. An examination of service users records found that some accidents involving service users had not been recorded in the accident book nor had they been notified to the CSCI and the manager must ensure this is addressed. Risk Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 7 assessments for how service users were to be supported in the community needed more detail. The manager must ensure the needs of the service users are being adequately met as one commented to the expert by experience that he had arguments with staff and wanted to live in his own flat. The expert by experience was concerned about this and thought the service user needed support from an advocate to enable the service user to work towards this. Three service users said they did not have any keys and the manager must ensure this is addressed. One of the service users was still waiting for work to be undertaken in making his en-suite shower cubicle more accessible. When prospective service users visit the service a record must be maintained of any day visits and overnight stays to show that the service user had tried the service before deciding whether to stay or decline the placement. 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.V281621.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.V281621.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): 2, 3, 4 & 5 Service users needs are assessed prior to admission to the service. There is no documentary evidence in place confirming prospective service users are involved in pre-admission visits to the service. Service users needs continue not to be met in full, as one requires showering facilities to met his mobility requirements. Service users have a statement of terms and conditions informing them of the fees to being charged by the service. EVIDENCE: Two service users were admitted to the service since the last inspection. One of them was a current resident who had spent a period of time in an assessment unit to provide support in managing changes in her mental health. There was evidence of assessments completed by various professionals including a Psychologist, Learning Disability Nurse and a Consultant Psychiatrist. There was evidence of reviews taking place prior to discharge from the assessment unit. Another service user admitted to the service had detailed assessments on file completed by a social worker under the Care Programme Approach within the Mental Health Act 1983. A representative from the organisation had also completed an assessment. However, there was no documented evidence in place to confirm whether the service user had undertaken a period of trial visits. The manager stated the service user had only visited the service once and was admitted straight from the psychiatric unit while she was on annual leave. At the time of this inspection the service user was in London having travelled there without knowledge of the staff and was currently in a psychiatric unit awaiting transfer to another in Birmingham. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 10 At the time of this inspection comments were made by a number of service users to the expert by experience. When asked what made them happy one of the service users said they liked going to visit their mother’s. Another said they liked going to watch the Blues play and was going to a match later that evening. Concern was expressed by the expert by experience that one of the service users commented he was fed up and felt like giving up because of arguments with staff and wanted to live in his own flat. It was noted that at the last inspection the particular service had also expressed his wish to live in his own accommodation. The expert by experience felt the service user should have support from an advocate to help him work towards this. Observations at the time of inspection found service users to be dressed appropriately for the climate of the day with positive support being provided by staff. While the service users needs were to a certain extent there was still issues around one service user who was still in need of accessible bathing facilities in his bedroom. The manager stated various contractors had been round to provide quotes for the work to be done and the Registered Individual had decided who was going to do the work. However, there was no date confirming when the work would be undertaken. At the time of publication of this report the manager had arranged for the service user to be visited by an Occupational Therapist to undertake an assessment of his mobility and bathing needs. Discussion with the manager identified that the service user who had recently returned from an assessment unit had undergone periods of aggressive behaviour. The manager was concerned that the service user was becoming less responsive to staff support and had refused to attend her day service. An examination of the service user’s care records indicated there had been a number of incidents of aggressive behaviour which has had a negative impact on the other service users with one making a complaint to the manager about the individual’s disruptive behaviour during the night. One of the service users’ commented that he was fed up with the service user “winding him up”. With these issues in mind the organisation must make a decision as to whether the placement is still appropriate for the service user. Since the last inspection there had been amendments made to the service users’ contacts stating the fees to be paid. Pines,The (Birmingham) Ltd DS0000004514.V281621.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 Service users have detailed care plans that set out how individual needs are met consideration should be given in making these more accessible. Service users are encouraged to make decisions about their lives through service users meetings but these must be held every month. Service users risk assessments require more detailed information around how service users should be supported in the community. EVIDENCE: At the time of this inspection three service users care records were examined. The manager had made improvements to the care plans in setting out service users’ daily routines including their preferred time of getting up and going to be and what were their favourite leisure activities. These had been reviewed since the last inspection and there was evidence indicating the service users or their relatives had signed them to confirm their involvement. In conversation with a number of service users the expert by experience commented that only one of the service users said she knew what a care plan was which was about something she did every day. She also stated her care plan was kept in the office. The expert by experience thought that the care plan should be more accessible to the service users. Consideration should be given in developing care plans in a more accessible picture/ symbol format so that the service Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 12 users have their own copy that is more person centred focussed. It is also recommended that the manager access training in person centred planning that would provide staff with a wider knowledge in how to develop person centred care plans. Two service users told the expert by experience there were residents meetings but these did not occur very often. An examination of the minutes for these meetings indicated there were meetings for September, November and December 2005 but none for October 05 and January this year. One of the minutes referred to the service users being given the opportunity to attend a local advocacy group but had declined this. There was also discussion about the meals and activities being provided. In discussion with three service users about managing their money one said he had a building society account but her mom looks after the money. Another service user said he gets a daily allowance of £6.35 so he could by cigarettes and one said the staff looks after his money. When examining individual risk assessments it was noted that those for supporting service users in the community such as going to football matches needed a more detailed breakdown to show how they were to be supported and with how many staff. Pines,The (Birmingham) Ltd DS0000004514.V281621.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): 11, 13, 14, 15, & 17 Service users with non verbal communication are supported by staff who uses appropriate signing. Service users participate in leisure activities in the community but could benefit in having more indoor activities when they don’t go out. Service users have a choice of varied and nutritious meals that meet their individual dietary requirements. Service users are able to maintain contact with their relatives but improvements are needed in assisting service users to maintain positive relationships with each other. EVIDENCE: A number of service users have limited verbal communication and the expert by experience was pleased with the way staff had communicated with one of the service users by means of signing. Observations at the time of this inspection found staff were encouraging service users to talk about how their day had gone when returning from their day placements. Two service users spoke with the expert by experience about how they spent their leisure time. One said she watched TV sometimes does knitting while another commented that he liked watching war films and goes out without staff support to a centre where he does work. The expert by experience felt that the service users could do with more opportunities for activities indoors Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 14 during the evenings such as arts and crafts when they don’t go out. An examination of the service users’ daily records indicated they had been out for pub lunches, bowling and visited the cinema. Since the last inspection a new DVD player and a digital channel set top box had been installed in the lounge. At the time of this inspection one service user had gone out to Stratford on Avon for the day. Another service user said that he was going out to a football match at Birmingham City in the Carling Cup and was excited about going. Another service user also supports Birmingham City and there was evidence in his daily records that he had been to most of their home games this season. There risk assessments in place stating how he should be supported when at the ground as he has epilepsy. One of the service users works at a local charity shop during the week and during the weeks leading up to last Christmas had got a casual job at Toys R Us. The expert by experience asked two service users about recent holidays. One commented he had gone to Tenerife while another said she had been to Cyprus but was not well enough to go this year. Improvements had been made since the last inspection with the daily recording of service users where staff were providing more examples as to where service users had gone out and for example what kind of films did they watch when going to the cinema. There was also reference to the kinds of TV programmes service users were watching. Three service users spoke with the expert by experience about their friends and families. One stated that she receives visits from her mother and has a sister who lives in London. The service user also said she phones her mother every night at seven in the evening and visits her every weekend. Another service user spoke about his family visiting him for his birthday the previous day where they had a party. The service user showed the expert by experience his birthday cards, which included one written by the staff. The expert by experience noted that the service users had access to a vehicle. During the inspection one of the service users commented that one of the others would always “wind him up” which he seemed very annoyed about. It was noted one of the service users had made a complaint about another who had been verbally aggressive during the night, which caused disruption to his sleep. The expert by experience discussed with the service users and staff about the meals provided. A staff member stated there is a set menu on a weekly basis. The service users are asked what food they would like for the week on Sunday. A service user confirmed this with the expert by experience. However, the expert by experience noted there was not an accessible menu on display in the kitchen although the written menu did show it was flexible. A service user stated that she goes out shopping with the staff and helps to choose the food. The expert by experience thought that the service users were offered lots of choices, which was good. In fact he thought it was great that staff were offering the service users more than one choice of meal for their tea. Pines,The (Birmingham) Ltd DS0000004514.V281621.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 Service users receive support with their personal care when they require assistance. Service users receive appropriate support with their healthcare requirements in the community and through specialist support services. Service users good health is promoted and maintained with appropriate management of service users medication. EVIDENCE: An examination of service users care records indicated where they had received support with their personal care including having a bath or shower. The expert by experience was told by a number of service users that they chose when to get up and go to bed and this was confirmed when examining their daily records. Manual handling assessments were in place and these had been reviewed since the last inspection. Discussion with the manager identified the need to develop individual health action plans in line with the Department of Health’s Valuing People Guidelines. The manager received these comments positively. Since the last inspection the manager had ensured all service users’ nutritional screening assessments had been updated. An examination of three service users care records indicated there was regular monitoring of their weight. There was documented evidence confirming when service users had contact with healthcare professionals such as GP, Dentist, Optician and Chiropodist. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 16 One of the service users pointed to his feet to say that he had seen the Chiropodist earlier in the day. Service users were also receiving specialist support from services within the Primary Care Learning Disability Trust. These included reviews of medication with a Consultant Psychiatrist. Improvements have been made with the management of service users’ medication since the last inspection. An examination of the Medicines Administration sheets indicated there were no gaps in recording. Any surplus amounts of medication from the previous MAR sheet period had been carried forward and those amounts were written on the MAR sheets. The medication policy and procedure had been amended to state that any errors in the administration of medication would be notified to the CSCI. The manager was undertaking regular medication audits of staff to ensure they maintained their competency. Standard 21 was not assessed in depth but the manager provided written evidence confirming service users were being consulted about their final wishes and funeral arrangements, which was a requirement from the previous inspection. Pines,The (Birmingham) Ltd DS0000004514.V281621.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 A complaint procedure is in place for service users but improvements are required in ensuring any complaints have been addressed to their satisfaction. Improvements have been made to the management of service users’ personal allowances protecting their interests. EVIDENCE: The CSCI have not received any complaints since the last inspection although when examining one of the service user’s care records there was a record of a complaint made concerning another service user’s behaviour. There was no evidence confirming whether this had been investigated with an appropriate outcome to the service user’s satisfaction. The expert by experience thought that the service users did not have any easy to understand complaints procedure displayed around the building. One service user said that she would talk to the staff if she was upset about anything or talk to her mom. Two service users stated they too would talk to the staff if they had concerns. Since the last inspection the manager and the organisation have taken action in ensuring the management of the service users’ personal allowances was being administered to an acceptable standard. The manager provided evidence confirming that those service users who had previously been charged for bedding and furnishings were reimbursed by the organisation. The policy and procedure for physical intervention had been amended to say that the CSCI must be contacted should physical intervention be used in an emergency. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 Service users live in premises that provide a clean, tidy and homely environment, but do not have keys to their bedrooms protecting their property and privacy. Not all service users have a suitable accessible bathing facility that is adapted to meet their mobility requirements. EVIDENCE: The premises was found to be clean, tidy and well maintained at the time of this visit. Since the last inspection a new washing machine with a sluice programme had been installed. Facilities for the removal of clinical waste had also been in place since the last inspection. During this inspection the expert by experience spoke to two service users about their bedrooms. The expert by experience was concerned that the service users did not know how they wanted their bedrooms decorated and two stated they wanted their rooms decorated blue. Three service users stated they did not have a key to their bedroom. One service user stated his shower did not work. There is still an outstanding requirement regarding one of the service user’s en-suite shower that does not meet his mobility needs. The shower cubicle requires the service user to step over and has limited room to move. The Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 19 manager stated that contractors had been round since the last inspection and quotes had been passed on to the organisation but there was still no date confirming when the work would take place. The Registered Provider must be mindful that if this is not addressed then the CSCI will consider enforcement action. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, & 35 Service users are supported by staff who are qualified to meet their needs. Service users would benefit in having levels of staffing to provide them with continuity of care and support. Service users are supported by staff who are offered and provided with training to enhance their development. EVIDENCE: There were three members of staff on duty during the day and the manager stated that since the last inspection one member of staff had been promoted to senior carer. One member of staff had left the service since the last inspection by mutual consent because the individual concerned was meeting the required standard. The manager commented there have still been problems with the current levels of staffing and has had to cover some shifts during the day. There are currently two full time care support workers vacancies of which one who had been interviewed is male. An examination of staff training records indicated four members of staff were completing LDAF training. Eight members of staff had completed training in awareness of autism. One member of staff had completed NVQ Level 2 and was starting on Level 3.Three members of staff were completing NVQ Level 2. Future training arranged was for risk assessing, epilepsy and first aid for appointed persons. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 21 During the expert by experience spoke to one of the service users about how people got on with staff and expressed concern with one of the responses. The service user commented that sometimes he has trouble with the staff because there are arguments. Another service user told the expert by experience she liked the staff and the manager. She was able to name her keyworker. During this inspection the interaction between the staff and service users appeared positive and at one point staff were watching television with the service users and the atmosphere was relaxed. Staff could be heard to involve the service users in talking about what was happening. The programme they were watching was Deal or No Deal. Staff were also observed to ask service users on arrival from day services how their day went. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41 & 42 Service users live in a home that is run by a manager who works towards improving better practice and is now being supervised by the organisation. There is a relaxed and friendly atmosphere that benefits the service users and staff. Service satisfaction surveys have been extended to staff and professionals enabling comments to be made about the management of the service. Service users interests are being safeguarded through the review of the service’s policies and procedures. The records were generally up to date for the safety and protection of service users, but improvements are required in maintaining and promoting their health and safety. EVIDENCE: The Registered Manager was present during the inspection and it was good to see that she had addressed the majority of requirements from the previous inspection. She acknowledged there was still improvements were required and confirmed she had completed accredited physical intervention training thus meeting one of the conditions of registration. The manager commented that she had gained more confidence in her role and that the organisation was more supportive with the introduction of monthly managers meetings to improve communication and to hopefully share good practice. She also stated Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 23 that one to one supervision was now in place on a monthly basis. Any comments made were received positively. The atmosphere overall was relaxed and friendly and the expert by experience commented that he thought the service users were safe. On arrival the manager asked the service user and his supporter for their ID before entering the premises. A representative from the organisation visits the service every month and there reports available for inspection. It was noted that the representative had spoken to service users and staff about how the service is being managed. Since the last inspection the manager had sent out a letter to the service users’ family and relatives informing them about the activities and events involving the service users over the last year. Satisfaction surveys had been completed by staff who raised a number of issues about the washing machine which had been acted upon by the organisation. Other comments made by staff were positive about the running of the service. The manager has been reviewing the policies and procedures ensuring they were up to date. The records seen during this inspection were generally up to date and locked away in a secure facility. Records with regard to health and safety were in need of improvement. There was evidence confirming the weekly testing of the fire alarms and the emergency lighting every month. A fire drill had taken place since the last inspection along with fire training. Records for the inspection and testing of the fire fighting equipment were also up to date. There was a risk assessment in place for the prevention of fire. The service had received a visit from a fire safety officer from West Midlands Fire Service and there was documented evidence that requirements made from his visit had been addressed. The expert by experience commented that the service users should have an easy to understand fire procedure. Improvements had been made regarding risk assessment for the premises which showed more detail as to how any identified risks should be managed. A new cupboard had been set up for the storage of materials used under COSHH Regulations and there was a folder with up-to-date product data sheets. An examination of the accident book indicated there were no significant numbers of accidents occurring since the last inspection. However, concerns were raised with the manager that two incidents of one service user falling out of bed had not been entered in the accident book nor reported to the CSCI via Regulation 37. There was also an incident involving a service user who had hit another service user in a vehicle that was not reported to the CSCI. The manager was instructed to ensure all staff referred to the Regulation 37 guidance issued by the CSCI that had been provided after the last inspection so there was a clear understanding of their role in reporting and recording incidents affecting the welfare of the service users. Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 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 N/A 2 3 3 3 4 2 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 N/A 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 N/A 2 2 N/A LIFESTYLES Standard No Score 11 3 12 N/A 13 3 14 3 15 2 16 N/A 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 3 3 3 3 2 N/A Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 25 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 YA29YA3 Regulation 12(1)(a) (b) 23(n) Requirement The Registered Person must ensure that service users with mobility difficulties have access to level shower facilities. Outstanding Requirement. Timescales 2 June 2005 & 23 October 2005 not met. The Registered Person must ensure that reviews are arranged to determine whether the service is still able to meet the needs of service users referred to in this report. The Registered Person must ensure written evidence is maintained of any pre-admission visits to the service by prospective service users. The Registered Person must ensure service users risk assessments provide more detail in how service users should be supported in the community. The Registered Person must ensure service users meetings occur every month. Timescale for action 07/04/06 2. YA3 12(2)(3) 07/04/06 3. YA4 12(2)(3) 07/04/06 4. YA9 13(4) 07/04/06 5. YA8 12(2)(3) 07/04/06 Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 26 6. YA15 12(5)(b) The Registered Person must ensure it encourages and maintains positive relationships between service users. 07/04/06 7. YA22 22(1) The Registered Person must ensure a record is maintained of any complaints made by service users ensuring any concerns are responded to promptly. It must state the outcome of any complaints investigation and action taken. The Registered Person must be given the opportunity to have a key to their bedroom. Any reason why they are unable to have a key must be documented in their care plan. The Registered Person must also ensure all shower units in service users’ bedrooms are working. The Registered Person must ensure appropriate levels of staff are maintained throughout the day and all vacant posts must be recruited to. The Registered Person must ensure any accidents involving service users are recorded in the accident book and are reported to the CSCI without delay. The Registered Person must ensure it develops a fire procedure in a suitable and accessible format. 07/04/06 8. YA24 12(2)(3) 16(2)(c) 07/04/06 9. YA33 18(1)(a) 07/04/06 10. YA42 13(4) 08/02/06 11. YA42 13(4) 23(4)(e) 07/04/06 Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 27 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. 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. 2. 3. 4. 5. YA8 YA14 YA19 YA22 Pines,The (Birmingham) Ltd DS0000004514.V281621.R01.S.doc Version 5.1 Page 28 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. 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