Inspection on 11/04/06 for 191 Redditch Road

This inspection was carried out on 11th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

191 Redditch Road 01/05/07

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 Unannounced Inspection 11th April 2006 10:05 Redditch Road (191) DS0000016959.V288532.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 Redditch Road (191) DS0000016959.V288532.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. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 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 Mrs Maxine Kallon Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 8th November 2005 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 service users needs, and operates a needs led approach, which aims to provide a high quality, residential service. Care is offered with normal lifestyle principles and service users 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. Service users 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. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced fieldwork visit was carried out over six and a half hours. This was the home’s key inspection for the inspection year 2006 to 2007. Five service users and the staff on duty were spoken to. The Manager was available for discussions for all of the inspection. One health professional was visiting the home at the time of the visit and was consulted on their views of the home. A tour of the premises took place. Care, staff and health and safety records were looked at. A pre-inspection questionnaire was also completed by the Manager and service users were sent comment cards prior to the visit taking place. Four comment cards were received from service users, two were received from relatives. What the service does well: The home has a nice friendly atmosphere. The staff were very friendly. The staff were very happy to questions from the Inspector. Observations revealed positive between staff and service users even though some individuals communication difficulties. The staff group is stable which is service users. Having a stable staff group gives continuity of care. answer the relationships have severe beneficial to Service users were well presented, dressed appropriately to their age and gender. Service users are well supported in their daily living tasks without losing their independence. Service users 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 service users with an attractive and homely place to live. Service user bedrooms are well maintained and personalised. The systems for service user consultation are generally good. Service users meet on a regular basis to discuss the home and issues important to them. There was lots of evidence that service users are able to choose what food they would like. Friends have the opportunity to visit the home and have a meal. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 6 The home ensure all the required recruitment checks are completed before new members of staff start work in the home. 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: Further work is required to develop care plans, which should include goals with outcomes that can be measured. The home must improve how it says it will help reduce risks for one service user regarding pressure area care. Medication management was generally well maintained, but clarification on the administration directions for some medication were required. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 7 Shortfalls were identified in regards to the home’s ability to safeguard service users by ensuring the appropriate checks are undertaken before agency staff commence work in the home. Whilst service users are offered lots of activities staff must ensure they are in line with their personal preferences. The quality assurance system requires development to make sure that service users views help to develop a plan for the home on how to move forward, thereby improving the overall quality of life for service users who live there. 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. Redditch Road (191) DS0000016959.V288532.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 Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. The Service User Guide provides prospective service users with relevant information about the home to enable them to make an informed choice about if they want to live there, progress has been made to ensure the format is suitable for all of the current service users. Admission procedures are satisfactory. EVIDENCE: Each service user has a copy of the service user guide. This is in both a written and picture format and contains all the required information. It was observed that the Manager is in the process of further developing these documents to make them more personal to individual service users and include further information on the complaints process. Consideration should be given to the use of video, photographs or audio tape when developing the guide to make it as user friendly as possible. The home does not have any vacancies and service users have not recently been admitted to the home so actual practice was not assessed regarding admissions. However, the admissions procedure was sampled in November 2005 and was observed to be satisfactory. Assessments would be completed prior to a new client being admitted to the home, followed by an initial review after four weeks, with a final review three months after admission to ensure that the client had settled into the home. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. Development of the care planning system is in progress to ensure all staff are provided with all the information they need to satisfactorily meet service user needs. Arrangements are generally adequate to ensure that service users are supported to take risks within a risk assessment framework but assessment for all identified risks must be completed. EVIDENCE: The home has a service user plan for each individual, which includes detailed profiles, activity plans, and daily recording. Two plans were sampled. The care plans were observed to require further development. Although the areas covered by the plan were generally holistic in the areas covered the content was not detailed in the exact support that service users needed. It is important that all plans contain sufficient detail to guide the reader in exactly how to provide support, and in sufficient detail. One plan did not contain adequate information regarding pressure care for the service user who may be at risk of developing pressure ulcers. It is an area of good practice that one service user has a care plan in a photograph and word format, making it easier for her to understand. Another Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 11 service user has a ‘communication passport’ that assists staff to interpret his body language and facial expressions as a means of communication. One service user had individual support strategies and guidelines. Some of these were not dated and so it was not possible to establish if they were subject to regular review. The plans recorded some short term and long term goal setting. Where goals are set the plan needs to record how they will be achieved and include dates for evaluation. Review meetings had been held in which one service user had participated. Review meetings need to reflect any progress made towards meeting goals. Discussion with the Manager indicates that Bourneville Village Trust is working towards introducing more service user friendly formats for care plans. This is work that several of the organisation’s home managers are contributing to. Service users are encouraged as far as possible to make decisions about their lives, this is done through regular service user meetings, attendance at reviews and 1:1 consultation. Observation of care practice evidenced that service users are consulted by staff regarding all areas of daily living. For example staff consulted with service users about what they wanted to drink before making drinks for individuals. Comment cards received from service users indicate that they generally make decisions about what they do each day. Some said this was daily but others said only sometimes. There is evidence that service users are supported to take manageable risks, and staff encourage individuals to have an independent lifestyle. For example one service user made his own hot drink on return home from an activity. Risk assessments were sampled for two service users. These were up to date with evidence of evaluation available. Some risk assessments were duplicated with several risk assessments being available for the same or similar risks. An assessment of the risk of one service user for pressure care was not available. Discussion with the Manager indicates that risk assessment is an area that she intends to further improve upon and that she had already identified a pressure care risk assessment was needed. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. Arrangements are in place so that service users experience a meaningful lifestyle. EVIDENCE: Sampling of care records and observation of practice indicate that service users undertake a wide range of activities, to include in house, day centres and in the community. On the day of the inspection all service users went out to various activities to include food shopping and to the barbers. One service user said that staff take her to church and to the Kennedy House disco which she enjoys. She also said that staff are taking her in June to see Chitty Chitty Bang Bang at the theatre. One service user has a visual impairment so he has lots of things put on to tape. Every week the Royal Institute for the Blind send him the weekly news on tape so that he can keep up to date with what is happening. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 13 Staff said that two service users were going away on holiday the next week to a themed musical event. One service user said he was really looking forward to going. All service users had aromatherapy from the visiting aroma therapist, some were clearly looking forward to their session. Whilst the staff team is commended for providing a good level of varied activities for all service users there was evidence that one service user is going to an activity, the disco, that he does not enjoy. It was clearly identified in his records that he does not like this activity, yet staff are continuing to take him. Three of the comment cards received from service users recorded that they can do what they want to do, but one said that they cannot always go out when they want to. Sampling of records and discussion with service users and staff indicates that service users are supported to maintain contact with relatives and friends. Some service users have visits from family or spend time at the homes of relatives. Friends have the opportunity to visit the home and have a meal. Staff were observed assisting service users to send out Easter cards to friends and family. There was lots of evidence that service users are able to choose what food they would like. They get together on a Sunday to talk about what food they would like to put on the shopping list. Photographic cards are used to assist individuals who have non-verbal communication to choose what they would like. One service user went out with staff to assist in shopping for food. Food stocks in the kitchen were observed to be plentiful with supplies of fresh fruit and vegetables available. One service user helped him-self to fruit on return from his activities. Two service users were asked about their views of the food provided, one said it was nice the other said it was okay. Menus and records of food eaten are maintained. The majority of staff record exactly what individuals have eaten whilst a minority had recorded ‘see menu’. This meant the reader had to keep referring from one set of records to the other to track what was eaten. A consistent recording approach is needed to ensure it is easy to track what food has been provided. Discussion with the Manager indicates that staff do not eat with service users at meal times as Bourneville Village Trust do not provide a food budget for this practice. The benefits of some staff eating with service users cannot be underestimated as this can make a mealtime more sociable for service users and staff can model good eating practice. Serious consideration must be given to reviewing mealtime practice. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. The health needs of service users are generally met with evidence of good multi-disciplinary working taking place on a regular basis, progress towards completing health action plans is evident. The systems for the administration of medication are generally good but clear directions for staff are not always in place to ensure service users receive the medication they need. EVIDENCE: Service users were all well dressed appropriately to their age, gender and the weather. One service user had been supported to have her nails varnished by staff, she was very pleased about this. Further detail needs to be added regarding personal support to care plans. For example do service users prefer a bath or shower, a wet shave or use an electric razor. Plans also need to take into account the personal preferences of service users with regard to the gender of staff who support them. Manual handling assessments were available for service users but these were observed to be undated. It was therefore not possible to establish if they had been subject to regular review. Sampled accident records indicate a low level of occurrence of accidents. There is evidence of service users receiving comprehensive health checks and monitoring, and detailed records are maintained. An Occupational Therapist is Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 15 involved with one service user who has been diagnosed as in the early stages of dementia/Alzheimer’s disease. Discussion with this professional indicates that she is satisfied with the care being offered by the home to meet this individuals needs. As stated earlier in this report, further work is required to ensure one service user has an appropriate risk assessment and plan to prevent pressure sores occurring. Additionally this service user requires staff to assist him in doing passive daily exercises. Records did not evidence this was being done. Discussion with the Manager indicates that some staff are not confident in doing this, therefore the Manager has arranged some additional training from the Physiotherapist. 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. Good progress has been made towards achieving this and each service user now has a plan, some of which are still being completed. The plans were observed to be detailed and provided some very good information for staff on the support needed by the individual to stay healthy. The systems for the safe handling and administration of medication were generally well managed. The home retains copies of prescriptions, and audits are undertaken of medication stocks. Staff have completed satisfactory medication training. A new member of staff confirmed that she was soon going to be attending this course. Medication administration competence assessments are not completed for staff. A format for this should be devised and assessments completed at least annually to ensure staff administer medication safely. Medication administration records were sampled. Some improvement was required as some recorded ointments that were no longer prescribed to the individual. This needs to be recorded on the record and the Manager must ensure that the pharmacist is requested to remove it from the next administration record. Some administration records also instructed staff to give some medications ‘as directed’, but there were no clear directions available. These are needed to ensure service users receive all the medication they need safely. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. The home has a satisfactory complaints procedure, appropriate action is taken on receipt of a complaint. Arrangements for protecting service users from risk of abuse need improvement. 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. Service users 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 service users. All of the comment cards returned from service users indicated they knew who to speak to if they were not happy, 75 were aware of the complaints procedure. One relative commented that they were aware of the home’s complaint procedure but another was unaware of it. The Manager needs to consider how further information can be made available to relatives. Training records show that all staff have completed adult protection and most have completed physical intervention training. It has previously been required that the policy of physical intervention is developed, in line with codes of professional practice. This has now been done. As the policy is basic in content it is recommended that the home also has a copy of the Department of Health’s guidance on physical intervention. At the last inspection it was identified that the adult protection policy needed some amendment to meet standards, this has now been done. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 17 Inventories are available to show the personal belongings of each service user. It is recommended that the format is improved so that staff are better able to track when new items are purchased and old items discarded. This will improve the safeguards in place for the protection of service users property. The finance records for one service user were sampled and found to be satisfactory. At the last inspection in November 2005 discussion with staff and previous Manager indicates that one service user has a history of saying things about staff that may not be true. It was therefore required that guidelines are in place to guide staff as to when things need to be reported to the CSCI and Social Care and Health under adult protection. To this end it was strongly advised that the home works with Social Care and Health and/or the Community Nurse in the development of such guidelines. The previous Manager of the home supplied an action plan stating this had been done. At this inspection the new Manager was unable to locate evidence that Social Care and Health and/or the Community Nurse had been consulted. Brief guidelines were available but did not guide staff adequately. Additionally the title of the document ‘Making false accusations’ could direct staff into thinking the accusation is false before appropriate consideration has been given. When agency staff have been used the supplying agency has previously supplied the home with details of CRB checks for their staff. This has not been the case recently. The Manager needs to ensure this information is provided to ensure appropriate safeguards are in place for service users. Redditch Road (191) DS0000016959.V288532.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, 26, 29, 30 Quality in this outcome area is good. The standard of the environment provides service users with an attractive and homely place to live and generally meets their needs. EVIDENCE: The home was seen to be generally well maintained, comfortable, and free from odour. Discussion with the Manager indicates that it is intended to have new carpet in the lounge, and the room redecorated in a more relaxing colour than the current vibrant yellow. Three service user bedrooms were sampled, these were all observed to be personalised and decorated to an adequate standard. Two service users spoken with confirmed they liked their bedrooms and had everything they needed. The access to the laundry is not possible for some service users as it is located on the first floor. This is not ideal and this has been documented within the statement of purpose. The laundry does not have a wash hand basin. At the last inspection it was recommended that consideration should be given to installing one. Discussion with the Manager indicates it is under consideration but that the water pressure upstairs might make this difficult. Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 19 Access to the kitchen is good and worktops are of differing heights to meet service user need. Communal living space does meet minimum requirements with regards to usable space but the lounge and dining area are all one room. The home does not benefit from having an additional communal room where service users could meet visitors in private. The home has a specialised bathroom with Arjo bath and aids and adaptations, and a separate level access shower facility, which appear to suit the needs of service users currently accommodated. Pressure area relieving equipment is also available. In the kitchen hygienic methods were noted to be being deployed. The inspector observed that a cleaning schedule was in place, fridge/freezer temperatures were being recorded and all foods were appropriately stored. Redditch Road (191) DS0000016959.V288532.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, 34, 35, 36 Quality outcome in this area is good. The arrangements for staffing the home, their support and development was generally good, outstanding training is in the process of being arranged. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. Support to service users is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. Comment cards received from service users generally record that they are happy with how they are treated by staff. The pre inspection questionnaire indicates that 90 of the staff have achieved the standard of having an NVQ in care. There are male service users at the home but there are no male staff employed. The Manager said that potential male staff had been interviewed but had proved unsuitable. Sampling of the staff rota indicates that adequate numbers of staff are on duty to meet service users needs. 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. The Manager does work some ‘hands on’ shifts but usually has three days per week designated for management and administrative tasks. The home has one night staff vacancy, use of agency staff has been limited to ensure consistency of care. It is a strength of this home that service users are usually Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 21 supported by staff who know them well. Comment cards returned by relatives of service users recorded that they were satisfied with the levels of staff. The recruitment records for two new members of staff were sampled. This contained all the information required and demonstrated that service users are protected by a robust recruitment process. A training matrix summarising the training of the staff team as a whole was not available at the last inspection. This has now been completed for areas of mandatory training and the Manager said it would eventually be extended to cover all training. Observation of records and discussion with staff indicate that there is a good program of training in place for staff to include adult protection, physical intervention, fire, food hygiene, dementia, confidentiality and equality and diversity. New staff had received a full induction. One area of training was outstanding for several staff as they had not received annual refresher training in manual handling. The Manager said that she was currently liaising with the trainer to agree a date for this training. Evidence show that staff are well supported. One member of staff spoken with felt she received a good level of supervision. The supervision records for three members of staff were sampled. The home has adopted a formal structure for these supervisions sessions, and those examined provided evidence of a good support process for the staff. Supervision is regular, for one staff it was overdue but arrangements were being made that day to ensure it took place. Staff meetings are held on a regular basis. Redditch Road (191) DS0000016959.V288532.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, 39, 42 Quality outcome in this area is adequate. The home is generally well managed. Adequate arrangements are not in place to ensure that service users or their representatives views underpin all selfmonitoring, review and development by the home. Health and safety of staff and service users was well managed. EVIDENCE: There has been a new Manager appointed since the last inspection who has recently been registered by the CSCI. The style of management in the home is relaxed, open and inclusive, and the Manager is making clear efforts to develop the service for the benefit of the people living there. The Manager has a significant amount of experience in care and is a qualified nurse for people with a learning disability. To fully meet the standard the Manager is currently undertaking the Registered Managers Award. There was evidence of the statutory reports being completed by the representative of the organisation on a monthly basis to evidence they are overseeing the running of the home and ensuring the health and welfare of the Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 23 service users. Discussion with the Manager indicates that the home does not have a continuous self monitoring system, using an objective, systematically obtained, reviewed, and verifiable method that involves service users. However plans are being made for an independent company to complete annual quality audits. Health and safety at the home was well managed. 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 received refresher fire training. Hoists and tracking systems are regularly tested. Certificates to evidence the testing of portable electrical appliances were available. A gas safety certificate was available but this showed the gas safety was due for rechecking in a few days time. The Manager agreed to forward a copy of the new certificate when it was received. Stickers on the fire extinguishers recorded that they had been serviced and the Manager forwarded a copy of the service certificate shortly after the visit took place. A valid certificate of employers liability insurance was available in the home. Redditch Road (191) DS0000016959.V288532.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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 3 X Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 25 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 Regulation Requirement Ensure the care plan details the specific support needs of service users to include personal care and pressure care. All plans and guidelines must be dated on production. Care planning- The Manager will need to ensure that agreements regarding goals and aspirations are documented regarding who will undertake the required action and the timescale for achieving it. Ways in which service users goals are to be met need to be transferred in to the care plan. Outstanding from 30/12/05 Ensure risk assessments are available for all identified risks. Ensure that activities offered to service users are in line with their personal preferences. Care plans need to take into account the personal preferences of service users with regard to the gender of staff who support them with DS0000016959.V288532.R01.S.doc YA6YA18YA19 12(1)(a) 15 Timescale for action 30/05/06 2. YA6 12(1)(a) 15 30/05/06 3. 4. YA9 YA12 13(4) 15 16(2)(m) 30/05/06 30/05/06 5. YA18 12(1) 15 30/05/06 Redditch Road (191) Version 5.1 Page 26 personal care. 6. YA18 12(1) 15 13(4) 13(2) Manual handling assessments must be dated on production and reviewed on a regular basis. Clear instructions must be available for the administration guidelines of all creams, ointments, medication. Medication no longer prescribed to the service user must be removed from the medication administration chart. In order to ensure that the protection of one specific client the Manager needs to ensure that adequate guidelines are in place to guide staff as to when things need to be reported to the CSCI and Social Care and Health under adult protection. To this end it is strongly advised that the home works with Social Care and Health and/or the Community Nurse in the development of such guidelines. Outstanding from 30/12/05 Ensure CRB information is obtained from supplying agency before new agency staff commence work in the home. Ensure all staff receive annual manual handling refresher training. A formal quality assurance system must be in place that seeks the views of service users and their representatives. 30/05/06 7. YA20 15/05/06 8. YA23 12(1)(a) 15 13(6) 15/05/06 9. YA23 13(6) 15/05/06 10. 11. YA35 YA39 18(1) 24 (1-3) 30/06/06 30/07/06 Redditch Road (191) DS0000016959.V288532.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. 2. 3. Refer to Standard YA17 YA17 YA20 Good Practice Recommendations A consistent recording approach is needed to ensure it is easy to track what food has been provided to service users. Serious consideration must be given to reviewing mealtime practice so that staff eat with service users. It is recommended that medication administration competence assessments are completed for staff. A format for this should be devised and assessments completed at least annually. Inventories. It is recommended that the format is improved so that staff are better able to track when new items are purchased and old items discarded. It is recommended that the home has a copy of the Department of Health’s guidance on physical intervention. The laundry does not have a wash hand basin, consideration should be given to installing one. This would improve the arrangements for infection control. (Manager states this is under consideration but that low water pressure might make this difficult) Consideration should be given to recruiting male staff to reflect the gender composition of the home. (Manager states that home has interviewed potential male staff but they were unsuitable) 4. 5. 6. YA23 YA23 YA29 7. YA33 Redditch Road (191) DS0000016959.V288532.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. Extracts may not be used or reproduced without the express permission of CSCI Redditch Road (191) DS0000016959.V288532.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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