Inspection on 01/05/07 for 191 Redditch Road

This inspection was carried out on 1st May 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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

191 Redditch Road 11/04/06

191 Redditch Road 08/11/05

191 Redditch Road 28/04/05

191 Redditch Road 26/10/04

191 Redditch Road 19/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Redditch Road (191) Kings Norton Birmingham West Midlands B38 8RH Lead Inspector Kerry Coulter Key Unannounced Inspection 1st May 2007 09:00 Redditch Road (191) DS0000016959.V334760.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 Redditch Road (191) DS0000016959.V334760.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. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redditch Road (191) Address Kings Norton Birmingham West Midlands B38 8RH 0121 680 2669 F/P 0121 680 2669 michelledwyer@bvt.org.uk 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) Bournville Village Trust Miss Michelle Dwyer Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 11th April 2006 Brief Description of the Service: 191 Redditch Road is a care home providing personal care and accommodation for five people with a learning disability. Bourneville Village Trust owns the home. The home operates a home for life as long as they can adequately meet peoples needs, and operates a needs led approach, which aims to provide a high quality, residential service. Care is offered with normal lifestyle principles and people are encouraged to bring personal possessions to the home. All rooms in the dormer bungalow are single occupation, with no rigid visiting hours or set mealtimes. People who live there are able to retire and rise when they prefer. They can also shop for, prepare and cook their own meals if they wish, and are offered a choice of leisure time activities geared to their individual needs and abilities. The home is fully equipped with hoists, changing facilities, an Arjo bath, with some bedrooms being fitted with ceiling tracking. The gardens to the front and rear have been designed for wheelchair users. Visitors to the home can request to see a copy of CSCI reports from staff as reports are located in the home’s office. Information provided by the Manager records that the fees for the home range from a minimum contribution of £63.95 per week to £98.60. This does not include personal items such as toiletries and magazines. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over eight hours. This was the homes key inspection for the inspection year 2007 to 2008. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, reports from the provider and a pre inspection questionnaire. Surveys were received from one relative, four health professionals and three people who live at the home. All people who live at the home were spoken to. Due to their communication needs some people who live at the home were not able to comment on their views. Therefore to establish what it is like to live at the home time was spent observing care practices, interactions and support from staff. Discussions with three members of staff and the Manager took place. One health professional who was visiting the home was spoken with. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: The staff were very friendly. The staff were very happy to answer the questions from the Inspector. Observations revealed positive relationships between staff and people who live at the home. Most of the staff have worked at the home for a long time which means they know the people who live there well. People have the opportunity to participate in lots of activities, some based in the home, some in the community. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. The standard of the environment within this home is good providing people with an attractive and homely place to live. Bedrooms are well maintained and personalised. People who live at the home meet regularly to discuss the home and issues important to them. There was lots of evidence that people are able to choose what food they would like and are offered a healthy diet. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 6 The home ensure all the required recruitment checks are completed before new members of staff start work in the home so that people are protected from having unsuitable staff working with them. Checks are done on equipment and the fire alarms to make sure people are kept safe. The Home is generally well run, and the style of management is relaxed, open and inclusive. What has improved since the last inspection? What they could do better: The way in which care plans are reviewed need to get better to ensure people who live at the home are fully consulted about their review and that it covers all their assessed areas of need. Improved planning is needed to increase opportunities for personal development. Care plans should include how staff should support people to develop new skills. Health monitoring records must be kept for all people at the home to ensure they receive the care they need to stay healthy. The laundry does not have a wash hand basin, consideration should be given to installing one. This would improve the arrangements for infection control. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 7 The quality assurance system could be improved to make sure that the views of people who live there help to develop a plan for the home on how to move forward, thereby improving the overall quality of life for people who live there. The Manager needs to ensure that training is arranged more quickly for staff who have been unable to attend mandatory training arranged for the staff team so that all staff have received the training they need to meet peoples needs. 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. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 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 Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to ensure they can make a choice about whether or not they want to live at the home. Procedures are in place to ensure individuals are fully assessed prior to admission to ensure that their needs can be met by the home. EVIDENCE: Each service user has their own copy of the service user guide. This is in both a written and picture format and contains all the required information. Consideration should be given to the use of video, photographs or audio tape to make it as user friendly as possible. There have been no new admissions to the home for some years and so this made it difficult to fully assess practice. Discussion with the Manager shows awareness of good admission practice. The admissions procedure was sampled and was observed to be satisfactory. Assessments would be completed prior to a new person being admitted to the home, followed by an initial review after four weeks, with a final review three months after admission to ensure that they had settled into the home. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 10 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 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Development of the care planning system is still in progress to ensure all staff are provided with all the information they need to satisfactorily meet individual needs and to enable people to be as involved as possible in their care plan. Arrangements are satisfactory to ensure that service users are supported to take risks within a risk assessment framework. EVIDENCE: The home has a service user plan for each individual, which includes detailed profiles, activity plans, and daily recording. Four plans were sampled and were all found to be up to date. Further development of the plans has taken place and a new format is in place that includes an assessment of need and a plan to meet those needs. Guidance for staff on how to meet individuals needs was observed to be more specific than the previous plans. There were a few gaps in detail but staff generally had most of the information they needed. Bourneville Village Trust has been actively seeking to improve systems for care planning but has recently changed the format several times without giving Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 11 formats time to be fully completed and embedded. Some consistency of format is now needed to ensure staff understand the systems in use. Staff have tried to include people who live at the home in the care planning process but practice in involving people in developing and reviewing the plan is variable. Plans had been regularly reviewed by staff but some improvement is needed to how reviews are carried out to include the individual in their review as much as possible. For one person the minutes of their review did not cover all areas of need and did not show how they had been involved. Target dates for agreed actions are not always set and the care plan did not track progress made towards the agreed actions. For another there were dated review forms in their file but they had not been completed. Staff are working towards plans being more person centred and people having a copy of their plan in a format they can understand. However this work has been ongoing for some time and needs to be completed. It is an area of good practice that one person has a care plan in a photograph and word format, making it easier for her to understand. Another person has a ‘communication passport’ that assists staff to interpret his body language and facial expressions as a means of communication. Staff are working on completing ‘Listen to me’ workbooks that record peoples likes, dislikes and preferences so that the care provided can be more person centred, however this information needs to feed into the care plan and not exist just as separate documents to ensure that the care provided meets peoples expectations. Members of staff were observed encouraging people to make choices about day-to-day matters, such as what to drink and what they wanted to do on that day. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. Staff sought permission from people before they went in their rooms. Staff were able to describe how people’s views were sought and choices were offered to people. The Manager said that some staff are shortly attending a course ‘Involving People Properly’ via an external trainer. One person has expressed the wish to move from the home, staff have respected this decision and facilitated a visit to look at another service. Minutes available show monthly meetings take place for people who live at the home where they are consulted about what goes on and things they would like to do. There is evidence that service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. Risk assessments were noted to be in place for the home and service user activities. These were up to date with evidence of evaluation available. As required previously risk assessments regarding pressure care had been completed. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people who live at the home experience a meaningful lifestyle. People who use services have good quality food and their diverse needs are well supported. EVIDENCE: There are opportunities provided for people to maintain and develop new skills, people were observed undertaking some basic domestic tasks such as taking used crockery back to the kitchen and helping with drink making. The staff and Manager spoke about one individual who had developed more independence when undertaking personal care tasks. However, despite opportunities being available it is quite ad-hoc and there is little planning regarding opportunities for personal development. From the care plans sampled it was not always clear what people could do for themselves regarding daily living tasks such as laundry and drink preparation. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 13 Discussion with people who live at the home, staff, sampling of records and observation of practice indicate that people undertake a wide range of activities, to include in house, day centres and in the community. Each person has an individual activity plan. Activities on offer include aromatherapy, snoozlum, disco, visits to parks, shopping, Church, Kennedy House, pub, circus, nature centre, library, walks and bowling. Individual needs are taken into consideration, for example one individual who has a visual impairment has visits from a dog from Pet Therapy and receives audio stories and news tapes. Another individual had requested more visits to the pub and staff had made sure this had happened. One person who lives at the home told me he had been doing some planting in the garden during the nice weather and enjoys helping staff water the plants. Minutes of people’s meetings show consultation regarding holidays, destinations include Ashgate and a cruise to Spain. Sampling of records and discussion with people who live at the home and staff indicates that people are supported to maintain contact with relatives and friends. Discussion with the Manager indicates that one person has an advocate from Mencap as they have no involved family. One person said he likes going to Linkways as he sees his friend there. Staff said that it was one persons birthday the next week. Therefore arrangements for him to go out with a friend from Linkways to celebrate have been made, he will then be spending time with relatives. There was no evidence of strict house rules. Staff were observed sitting and socialising with individuals. People who live at the home are able to choose whether or not to spend time with others, or to have private time in their own rooms. Staff at the home have recently received training on dyspagia (an eating problem) and good nutrition for people with dementia. Knowledge gained has had a positive impact on meal time outcomes for people who live at the home. There was lots of evidence that people are able to choose what food they would like and have a healthy balanced diet. Some individuals are on special diets and see the dietician regularly. Two people spoken with said that the food at the home was good. Lunch was soup and / or cheese on toast with ice cream and peaches for dessert. Staff gave appropriate support in line with care plans in a friendly tone of voice. For the individual who has a visual impairment staff told him where the food was positioned on his plate. Staff spoken with felt that an area of improvement since the last inspection was that people had a more healthy diet. Their view was supported by the menus and food records sampled. Lots of fresh fruit was observed to be readily available in the kitchen, and was not stored out of peoples reach. Staff said they were also hoping to start growing their own vegetables in the new raised bed in the garden. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 14 Staff did not eat with people at lunchtime. Staff spoken with said they eat with people on a Sunday. The Manager said that there had previously been no budget at all for staff to eat with people and the opportunity to eat on a Sunday was an improvement on previous practice. Consideration should be given to extending this to other days. The benefits of some staff eating with people who live at the home cannot be underestimated as this can make a mealtime more sociable and staff can model good eating practice. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and require and their health needs are well met but recording around some healthcare needs to improve. The management of the medication protects people and ensures their well-being. EVIDENCE: Care plans sampled around personal care needs were much improved, individual preferences have now been recorded that respect individuals diverse needs. This includes the gender of staff who supports people, however preferences cannot always be met due to the gender balance of the staff team not reflecting the people in the home. People met with had been supported by staff to look well groomed and were dressed appropriately to their age, culture, gender and the warm weather. All Staff gave appropriate support in a friendly tone of voice. One person was observed being supported by staff to have a drink. Time was given by staff between each sip so that the drink was given at the persons own pace. Staff spoke to him in an encouraging manner throughout. Where people need support from staff in moving and handling there were satisfactory assessments in place so that staff knew how to support the person safely. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 16 Surveys were received from four healthcare professionals, all were positive in their comments about the home, they all thought that the care staff were knowledgeable about peoples needs and contacted the professional when advice was needed. Discussion with staff and sampling of records show that in general peoples health needs are being met although recording systems did need some improvement. Some people have fluid balance charts that staff complete to monitor that they are having enough to drink each day. Observation of the charts shows that people are getting enough to drink. One person sees the dietician monthly in line with their care plan. They are on a high calorie diet to gain weight and records show they are slowly gaining weight. At the last inspection it was identified that some improvement was needed to care planning around people’s pressure area care. This has now been done and where needed risk assessments and care plans are in place. Some further improvement is still needed when staff are recording that people have a red area on their skin as they must remember to record when it has got better. Staff spoken with were aware of the health needs of individuals and said that links and input from other health professionals had improved. Where people have been unwell discussion with staff and observation of records shows that staff ensure they see the relevant health professional and that appointments are followed up if the person remains unwell. For four of the people who live at the home there was evidence of annual health checks such as the dentist and optician but for one person the records were not in his file. The Manager said he had attended appointments and was able to show a dental appointment had been scheduled the previous week but unfortunately this had been cancelled by the dentist. Staff record such visits on loose leaf paper and so it is quite easy for the records to be lost or mislaid. It is recommended that an annual tracking document for health appointments is introduced so that at a glance staff can access dates of previous appointments. It was recommended previously that Health Action Plans should be implemented. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. The Manager said that a plan has been completed for each person with the GP but that the home does not have a copy. It is recommended that a copy is requested from the GP so that people have a copy of their own plan. The systems for the safe handling and administration of medication were well managed. Medication storage was observed to be satisfactory. Medication administration records sampled had been appropriately signed to show that people had the medication they needed. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 17 The home retains copies of prescriptions, and audits are undertaken of medication stocks. Staff have completed satisfactory medication training. Since the last inspection manager has introduced an annual assessment to ensure staff are competent when administering medication. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and that their views will be listened to and acted on. Arrangements are sufficient to ensure that people are protected from abuse, neglect and self-harm. EVIDENCE: Discussion with the Manager indicates that the home has not received any complaints since the last inspection. The CSCI has not received any complaints regarding this home in the last twelve months. The home has a satisfactory complaints procedure. A summary of this is on display in the hallway. People who live at the home have a copy of the procedure in the service users guide. This is available in a format that includes pictures. Minutes of meetings show that the procedure has also been verbally explained to people. All of the comment cards returned indicated they knew who to speak to if they were not happy. The survey from a relative shows they are aware of the procedure and that the home has responded appropriately if concerns have been raised. The financial records of two people who live in the home were sampled and robust procedures were in place to safeguard their money. Receipts of all expenditure were available and two staff sign the record of each transaction. Inventories are available to show the personal belongings of each person, these were observed to up to date and track when new items are bought and old ones discarded. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 19 As required from the last inspection the guidelines for staff regarding one person who has a history of making allegations have been reviewed. It directs staff to report allegations to the Manager, ensure the CSCI are notified and follow Protection Of Vulnerable Adults (POVA) procedures. Discussion with the Manager indicates no allegations have been made since staff have facilitated the individual to have a more active social life. Discussion with a member of staff shows they knew what to do to keep people safe if an allegation was made. Training records and discussions with staff show they have had POVA training. The Manager said that POVA refresher training was booked for some staff the following week. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 20 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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: The home was seen to be well maintained, comfortable, and free from odour. Two bedrooms were sampled, these were all observed to be personalised and decorated to a satisfactory standard. The rooms were very personalised and met issues of diversity re age, gender and culture. The lounge and diner was observed to be newly decorated, with new carpet, seating and dining furniture. The room is now contemporary in style but homely with lots of picture, ornaments and photos of the people who live there. One person who lives at the home said he likes the new lounge. Discussion with the Manager indicates there are plans to refurbish the kitchen and hallway flooring in the next 12 months. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 21 The home has the necessary equipment and adaptations to meet peoples individual needs, to include mobility issues. The home has an assisted bathroom, where grab rails and a hoist are provided. One person has an overhead ceiling tracking system in their bedroom. There is ramped access to the garden. This year the garden area has been improved to provide an extra path and raised beds to improve accessibility for the people who live there. Infection control procedures in the home are good. At the request of the Manager the Health Protection Nurse visited in May 2006 and did an audit. Outcomes were judged as good. The outstanding issue was identified regarding the home having no wash hand basin in the laundry and the Nurse advised the use of alcohol gel as a short term measure until a sink is fitted. The Manager said she now has the budget to install one and this will be done. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 22 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, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home benefit from a well trained and supported staff team that can support them to meet their individual needs. People are protected by the home’s recruitment practices. EVIDENCE: Support to people who live at the home is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Staff spoken with had a good awareness of individual needs and how to meet them. The pre inspection questionnaire indicates that 90 of the staff have achieved the standard of having an NVQ 2 or above in care. The home have a very stable staff team, there have been no new starters since January 2006 and no staff have left since the last inspection. This means the staff know the people who live at the home well. There are generally three staff on duty during the day. At night there is one waking night staff and one member of staff sleeping –in. Discussion with staff and observation of practice shows this is enough staff to meet people’s needs. People’s requests for assistance were quickly responded to. Staff spoken with said there was time to sit and chat with people who lived there. There is some use of bank staff and Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 23 occasional agency staff. Discussion with staff and observation of the rota shows that agency staff never work alone, and during the day they work with two BVT staff. As previously required the Manager has obtained confirmation of agency staff Criminal Record Bureau checks being undertaken to ensure staff are safe to work with people. Recruitment records of permanent staff show that robust recruitment procedures are followed for the protection of people who live at the home. Staff spoken with were generally happy with the training on offer, they said they get the training they need to meet peoples needs. The training matrix shows that the majority of staff have had the training they need to meet peoples needs, one staff needed first aid and manual handling training and this is being arranged by the Manager. Some staff needed refresher fire training, the Manager said this would be completed soon. Staff said the recent dementia and nutrition course had been very useful. The Manager said that some staff are shortly attending a course ‘Involving people properly’ and ‘life stories’ via an external trainer. Some staff have attended dysphagia training with further training planned for September. Evidence shows that staff are well supported. Formal supervision is regular, and annual appraisals are also completed. Staff meeting minutes show these happen regularly. A new staff forum was recently introduced for BVT services, representatives from each home attend. Staff said it is an opportunity to speak with the Director of Care without the presence of home managers. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 24 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, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that people who live in the home or their representatives views underpin self-monitoring, review and development by the home. Health and safety was generally well managed to reduce the risk of accidents or injury to people who live at the home. EVIDENCE: The Manager has a significant amount of experience in care and is a qualified nurse for people with a learning disability. Staff said the Manager is open, approachable and listens to views of others. Discussion with the Manager shows she has a good understanding of where improvements have been made and also of areas where they need to improve. The Manager was professional throughout the visit and responsive to suggestions for improvement. It is good that most of the recommendations from the last report have been implemented. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 25 There are systems in place to assure quality and the views of people who live at the home are listened to. The systems in place do not always fully link together. Peoples meetings take place but outcomes do not feed naturally into a quality assurance system. The Provider’s representative visits the home monthly, reports are available. The new format for the reports is more detailed than previous formats. Health and safety at the home was generally well managed. The last report from the Environmental Health Officer in June 2006 was good and the recommendation regarding the storage of waste has been met. Monthly health and safety audits are completed. An examination of the home’s fire safety records indicate that routine testing of alarms and lights is being carried out. The records also show that fire drills are being routinely carried out. Staff have fire training via a mixture of external training and in-house but a minority of staff had not had attended the recent refresher training. The Manager said that these staff would receive in house training via a video. Service certificates were available for fire alarms and manual handling equipment- hoist, bath and ceiling tracking, to show they are well maintained. A gas safety certificate was available but this showed the gas safety was due for rechecking in a few days time. The Manager was able to evidence that the gas engineer had been booked to do the safety check. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 2 X X 3 X Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement The review of the care plan must cover all aspects of assessed need so that peoples care meets their expectations. Health monitoring records must be kept for all people at the home to ensure they receive the care they need to stay healthy. Timescale for action 30/08/07 2. YA19 12(1)(a) 30/07/07 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 Person centred information needs to feed into the care plan and not exist just as separate documents to ensure that the care provided meets peoples expectations. Care plans should be available to people in a format they can understand. Improved planning is needed to increase opportunities for personal development. Care plans should include how staff should support people to develop new skills. Opportunities for staff to eat with people at the home DS0000016959.V334760.R01.S.doc Version 5.2 Page 28 2. 3. YA6 YA17 Redditch Road (191) 4. 5. 6. YA19 YA29 YA35 7. YA39 should be increased to model good eating practice. People should have a copy of their ‘Health Action Plan’ so they know what care has been agreed and to ensure it meets their expectations. The laundry does not have a wash hand basin, consideration should be given to installing one. This would improve the arrangements for infection control. Refresher training for the member of staff who has missed out on manual handling and fire training needs to be completed as soon as possible to ensure people who live at the home are supported by staff who can meet their needs. Quality assurance systems need improvement to ensure the different methods used link together and lead to the production of a development plan for the home. Redditch Road (191) DS0000016959.V334760.R01.S.doc Version 5.2 Page 29 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. 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