Inspection on 29/11/06 for Sayer House

This inspection was carried out on 29th November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sayer House 18/01/06

Sayer House 16/06/05

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 Sayer House 2 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF Lead Inspector Sarah Bennett Key Unannounced Inspection 29th November 2006 10:05 Sayer House DS0000062605.V317315.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 Sayer House DS0000062605.V317315.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. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sayer House Address 2 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 443 2871 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) South Birmingham Primary Care Trust Family Housing Association Limited Ivy Winters Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A qualified nurse must be working in the home at all times and must not have responsibility for any of the other Newholmes bungalows. 18th January 2006 Date of last inspection Brief Description of the Service: Sayer House was previously registered as part of the Newholmes registration of six bungalows. In May 2005 the homes were registered separately. Sayer House provides nursing care to six people who have a learning disability. The statement of purposes states, “ Sayer House aims to provide end of life care to service users with Down’s Syndrome and dementia.” A category for dementia (DE) is to be imposed on the registration of the home. Sayer House is a six-bedroom bungalow that is fully accessible to all residents. Communal areas consist of an open plan kitchen, dining room and lounge. There is an additional small room off the lounge. There is a bathroom, shower room and a separate WC. Ceiling track hoists are fitted in bedrooms and bathrooms. Adapted bathing and shower facilities are provided. To the side of the bungalow there is a garden with grassed areas, pots and hanging baskets. The garden has a fence around it making it private. The home is situated in the grounds of what was once Monyhull hospital. However, a new housing estate has been built around the bungalow which now makes it part of the local community. Family Housing Association owns the premises. The home is managed and staffed by South Birmingham Primary Care (NHS) Trust. The range of fees charged as stated by Family Housing Association is £1188.81 per week. The CSCI inspection report is available in the home for visitors to read if they wish to. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, letters from relatives and reports from the provider. One inspector carried out the unannounced fieldwork visit over five and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. The Manager and the staff on duty were spoken to. Conversations with some residents were limited due to their complex needs and limited verbal communication. The inspector met with five of the residents and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: The staff team provide a specialist service to people who have a learning disability and dementia and because of this are coming to the end of their life. A relative told the CSCI, “ There should be more places like Sayer House so that other people can get the excellent care from staff that my relative had.” Staff make sure when residents are well enough they go out to places in the community that they would like to go to. Staff spend time sitting and talking to individuals and finding out what they need to make their life as comfortable as possible. Staff support residents to go on holiday so ensuring that despite their illness they can still experience visiting other places. Resident’s bedrooms are well decorated and reflect the tastes and interests of the individual. The home is well decorated, homely and comfortable. Individuals have their own comfortable specially adapted chairs so that they do not have to sit in their wheelchairs all the time. Staff have the training they need so they know how to meet the individual needs of residents. Other health professionals are involved in the care of individuals to make sure that all their health needs are met. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 6 Each resident has a Health Action Plan. This is a personal plan about what a person can do to stay as healthy as possible and what healthcare services they need to use. Staff take care in making sure that residents are as relaxed as possible which helps them to be comfortable and relieves their anxieties. There is a relaxed and calm atmosphere in the home, which helps this. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make a choice about whether or not the home can meet their needs. Prospective residents individual aspirations and needs are assessed before they move into the home. EVIDENCE: The statement of purpose of the home had recently been updated and included all the relevant and required information. The Manager said that she plans to put a photograph on the front to make it more personal. The service users guide to the home had been recently updated. This was produced using pictures making it easier to understand. All residents had a copy of this in their bedroom. It included all the relevant and required information. An admission process is in place that states that prior to admission an assessment is carried out of the individuals needs to ensure that these can be met at the home. One of the residents had been admitted two weeks before and their pre-admission assessment was completed in September. Once it had been identified that their needs could be met they visited the home to meet staff and other residents so they could get to know people before moving in. Their relatives also had an opportunity to visit with them. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs and goals are reflected in their individual care plans so that staff know how to support each individual. Residents are consulted on what goes in the home and are supported as much as possible to make choices in their day-to-day lives. Residents are supported to take risks within a risk assessment framework so keeping them safe from harm. EVIDENCE: Two residents records were sampled. These included an individual care plan. These stated how staff are to support the individual to meet their needs including health, communication, social and leisure activities and personal care. Care plans were detailed and included the advice of other professionals. Care plans included how to recognise pain and discomfort in the individual. This was assessed using a Disability Distress Assessment Tool. This looked at facial appearance, vocal signs, habits, mannerisms, posture and observations Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 10 when content and when distressed. A record of signs of pain or discomfort was kept that stated what action staff take, the effect it had and if any further action was required. The Manager said these are being developed for all individuals so that staff can ensure that individual’s pain is controlled as much as possible. Records showed that residents are consulted on what goes on in the home and are supported to make choices as much as they are able to. When residents had died staff spent time with other residents informed them what was happening and said they were there to support and reassure them if needed. Records showed that residents had been told about new residents moving in and they had an opportunity to meet the person where possible before they moved in. Records showed that staff had explained the complaints procedure to individuals. They had also discussed what they wanted to do for their birthday, where they wanted to go on holiday, activities inside and outside the home and what things they would like to buy for their bedrooms. Staff were observed offering residents choices of what they wanted to drink, what they wanted to do and where they wanted to spend their time. Records sampled stated where individuals were offered choices about what to wear, what to drink and where to spend their time. Records sampled included individual risk assessments. These were detailed and regularly reviewed. They included how to minimise the risks of harm to the individual when using bed rails, falling, eating and drinking, travelling in vehicles and having an epileptic seizure. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 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 in the home experience a meaningful lifestyle. Residents are offered a healthy diet and staff support them appropriately at mealtimes. EVIDENCE: One resident attends a day centre. Staff said that they hope that the individual can continue to go as long as they are able to as they enjoy going. There is a sensory unit in the lounge that has a bubble tube, fibre optic lights and a projector that projects images onto the ceiling. This can be stored compactly in a corner of the lounge so that it does not take up too much room. Residents were sitting around the sensory unit in the morning, with relaxing music playing in the background whilst staff were giving them a hand and foot massage. Residents seemed very relaxed in this environment and not in any pain or discomfort. Staff spent time talking to individuals creating a relaxed and pleasant atmosphere. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 12 After lunch residents spent time resting on their beds so that they had a change of position from sitting in their lounge chairs. Some residents listened to music, some watched TV and others went to sleep or relaxed with their sensory lighting in their bedroom. Records sampled showed that residents go shopping, to church, watch videos and DVD’s, listen to music, have the sensory lights on, have a massage from the Massage Therapist, have hand and foot massages and watch TV. Staff said that all residents apart from one person who had moved in two weeks before have been on holiday this year either to the Cotswolds or Blackpool. Staff said that residents keep in contact with friends and family as much as possible. Staff are going to support one resident to go to a Christmas Party at the day centre they used to go to. The Manager is going to support one resident to go out for a Christmas lunch with the people from the home where the individual used to live. Records showed that friends and family visit the home regularly. Staff were observed knocking on individual residents bedroom doors before entering. Residents were offered an opportunity to spend time in private. Staff respected the wishes of individuals if they wanted to sleep or rest rather than join in an activity. Menus included an alternative for each meal. Menus showed that a variety of food is offered that includes fresh fruit and vegetables. The food cupboards were well stocked, as were the fridge and freezers. A large variety of hot and cold drinks were available. Fresh fruit and vegetables were available. The Speech and Language Therapist has made recommendations as to the consistency of food and drinks for each individual to prevent them from choking. These individual guidelines were displayed in the kitchen as a quick reference for staff as they are preparing food. Staff sat with residents at lunchtime talking to them and supporting individuals where appropriate. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the personal and health care needs of individuals are well met. The arrangements for the management of the medication protects residents. The ageing, illness and death of an individual are handled with respect and as the individual would wish. EVIDENCE: All residents were well dressed and had individual styles of dress and hair. Residents were dressed appropriately to their age, gender, the weather and the activities they were doing. Staff took residents to their bedroom to change their clothes as and when needed for example if they had spilt a drink on their clothes. Care plans detailed how staff are to support individuals with their personal care. Resident’s records sampled included individual moving and handling assessments. These stated how staff are to support individuals with their mobility ensuring that the risk to the individual and staff are minimised as Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 14 much as possible. These were detailed and regularly reviewed. Records sampled showed that where individuals could walk staff supported them to remain as mobile as possible. Most residents are unable to walk unaided and spend time sitting in their own specially adapted comfortable chairs or their wheelchairs. Staff were observed always telling the individual what was happening and where they were going if they moved the person from one room to another. Staff going off duty after their shift were observed saying goodbye to each individual and telling them when they would next be on duty. Resident’s records included a pressure area assessment that was reviewed monthly to ensure that steps are taken to reduce the risks of individuals developing a pressure sore. Records included a nutrition assessment to ensure that individual’s dietary needs are met and they are not under nourished. Residents records sampled included a Health Action Plan. This is a personal plan about what a person needs to meet their health needs and what healthcare services they need to use. The plan included pictures making it easier to understand. It detailed how individual health needs are going to be met and who is responsible for ensuring they are met as much as possible. Other health professionals are involved in the care of individuals. These include the Older Adults Nurse, the Psychiatrist, Psychologist, Dietician, Speech and Language Therapist, Physiotherapist and Massage Therapist. Records showed that referrals had been made to the relevant health professionals for a resident who had recently moved in to ensure their health needs are met. Residents are weighed weekly and a record of this kept. Records showed that staff monitor the weight records to be aware if the individual is gaining or losing too much weight. Advice is sought from the Dietician if there are any concerns about individual’s weight. Records showed that individuals have regular dental check ups, eye tests and see the chiropodist where appropriate. The Massage Therapist has shown staff how to do hand and foot massage. Staff said that residents have these daily and it was observed that residents were very relaxed after this. Resident’s skin appeared well moisturised so making the individual feel more comfortable. The Speech and Language Therapist in a letter to the Manager in July 2006 stated, “ All your staff are excellent in communicating with the residents and I have observed high levels of engagement, information giving and choice.” Medication is stored in a locked cabinet. Boots supply the medication to the home using the monitored dosage system in blister packs. At the front of each resident’s Medication Administration Record (MAR) there was a photograph of the individual so it is clear whom the medication is to be given to. All MAR Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 15 were signed appropriately and these cross-referenced with the blister pack indicating that medication had been given as prescribed. Where individuals are prescribed as required (PRN) medication a protocol is in place stating when, and why this should be given to the individual. The home provides a service to individuals who are at the end of their lives. Records showed that thought is given as to how individual’s spend these days and as much as possible if the person is well enough staff give them opportunities to enjoy new activities and experience new things. Staff spoke about how families are involved in their relative’s life, as this is important. The Manager is undertaking a Degree in Palliative Care. The Manager said that she plans to develop with staff and individuals care plans around spirituality and dignity to ensure that the needs of individuals are met in these areas. A Senior Manager sent a letter to staff following the death of a resident, it stated, “ Thank you to you all for hard work and thought that you put into (the individual’s) funeral.” Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s views are listened to and acted on. Arrangements are generally sufficient to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is produced using pictures making it easier to understand. Each resident had a copy of this in their bedroom. There have been four occasions when one relative has raised concerns about the care of their relative and the location of the home. Records showed that staff had worked with the relative, the individual residents social worker and other members of the family to try and resolve these issues. The CSCI had been informed of these concerns. From inspections there was no evidence that these concerns could be substantiated with the exception of the location of the home from the residents relative. However, there are unfortunately no services that provide this care near to where their relative lives. The Manager had arranged a review with the Multi-Disciplinary Team of professionals working with the individual and their relative to look at ways of relieving these concerns. There had been several compliments about the home and these had been recorded. These were from relatives, student nurses that had been on placement at the home and Senior Managers. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 17 The Manager said and records showed that all staff are booked to attend training in adult protection and the prevention of abuse in December and January. Two residents financial records were sampled. These showed that individuals spend their money on personal items not on things that the service should provide. The records cross-referenced with the amount in their individual purse and wallet. Receipts are kept of all expenditure. Records sampled included an inventory of the individual’s belongings. These had been regularly updated when the person had bought new things or thrown anything away. This helps to ensure that it is easier to identify if any of the residents belongings should go missing. Two of the three staff recruitment records sampled did not include all the required records. The Manager said that these were currently at the Trust’s Head Office. These must be available in the home so it is clear that residents are protected by the recruitment practices. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are good so that residents live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: The home was well decorated and maintained throughout. Several bedrooms and the hall were being redecorated at the time of the last inspection and this had now been completed. A new carpet had been fitted in the hall and in some resident’s bedrooms. There were fresh flowers around the home and photographs of the residents making it look homely. At the front door there are several plant pots and baskets as well as a large wind chime that reflects the peaceful atmosphere of the home before you enter. Staff said that a new carpet had been delivered for the office and they were waiting for it to be fitted. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 19 The flooring in the shower room had been re -laid as staff said that before there was a problem with the water draining away. Staff said that this had made a big difference. Since the last inspection the kitchen units had been resealed where needed to minimise any risk of cross-infection as some were worn at the sides and there were gaps. The Manager said that the kitchen is to be refurbished and the units are going to be replaced. They have involved residents as much as possible in choosing the design for the new kitchen. The handle on the fridge door was broken and was sealed with tape. Staff said that a new handle had been ordered and they were awaiting delivery. Resident’s bedrooms were well decorated and furnished. Resident’s bedrooms were decorated according to individual tastes, interests and needs. Bedrooms reflected individual’s cultural and religious backgrounds. Bedrooms contained many personal items and sensory lighting so making the room relaxing and comfortable for the person to spend time in. Aids and adaptations are available to help residents move around including hoists and adapted bathing and shower facilities. An engineer regularly services these to make sure they are kept in a good condition and safe to use. Since the last inspection a new minibus had been provided. Staff said that this is better adapted to make it easier for residents to get in and out of. The home was clean and free from offensive odours throughout. An infection control plan is in place so that staff know how to sterilise the commode pans and toilet frames to prevent the risk of cross-infection. Hand towels, hand wash and toilet rolls were provided in all toilets. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing vacancies could impact on residents always being supported by an effective staff team that know them well. The staff that work at the home are competent, qualified, appropriately trained and well supported to meet individual’s needs. It is not evident that the current recruitment practices protect residents. EVIDENCE: The statement of purpose stated that six members of staff have NVQ level 2 in Health and Social Care and another member of staff has enrolled to do this. This meets the standard that at least 50 of care staff have NVQ level 2 or above. Staff meeting minutes showed that there had been six staff meetings in the last year, which meets the standard of at least six in a year. Staff meetings were also used as development opportunities for staff with other professionals visiting and staff learning about Dementia Care and Person Centred Planning. The Manager said that there are four vacancies for care staff, one on nights and three on days. The Manager said she interviewed for new staff recently but Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 21 there was nobody suitable to work at this home, mainly because of the distance they would have to travel to work. Staff working extra hours and regular bank staff are used to cover the vacancies. Agency staff are not used. Rotas showed that minimum staffing levels are met at all times. The Manager said that staff are very flexible in changing shifts if needed to ensure that staff that know the residents well are always on duty. Since the last inspection one care staff had started working at the home. It is to be commended that despite the staffing shortages the residents receive a good standard of care as highlighted throughout this report. Three staff records were sampled. The Manager said that for one of these members of staff there was not yet evidence in the home that a Criminal Records Bureau (CRB) check had been completed. It had been completed but evidence of this was still at the Trust’s Head Office. A CRB check had been undertaken for the other two members of staff before they started working at the home. This is to ensure that suitable people are employed to work with the residents and evidence must be available in the home. For one member of staff there was no evidence that two written references were available. The Manager said these were also available at the Head Office. Staff records showed that staff had received training in moving and handling, first aid, autism, epilepsy, dysphagia (swallowing difficulties), food hygiene, medication, basic massage, communication, infection control, healthy eating and person centred planning. All staff are currently doing the NVQ 2 in Health and Safety. This is a distancelearning course with a local college. The Assessor visited during the morning and said that all staff had done well and would be finished about a month earlier than expected. All staff are enrolled to do NVQ 2 in Dementia. Staff records showed that staff have regular, formal, recorded supervision sessions with their manager. They discuss their job role, the needs of the individual residents and identify any training and development needs they have. The Manager said that a psychologist is working with the staff around loss and bereavement, as it can be difficult to work closely with people who are at the end of their lives. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 residents benefit from a well run home. Arrangements are now in place to ensure that residents and their representative’s views underpin all self-monitoring, review and development by the home. Arrangements are generally sufficient to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: The Registered Manager is a Registered Learning Disability Nurse and is currently undertaking a Degree in Palliative Care. She has an NVQ in Dementia as well as NVQ 4 Registered Managers Award and D32/33 NVQ Assessors Award. It is clear from the outcomes experience by residents that the Manager gives a clear sense of direction so ensuring that the home is well run. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 23 A Social Care Manager from the Trust visits monthly to complete an audit. A report of this is forwarded to the CSCI. Since the last inspection a representative from Family Housing Association had visited as required under Regulation 26. The report of their visit cross-referenced to the National Minimum Standards and stated the evidence of outcomes for the residents. South Birmingham Primary Care Trust has developed a quality assurance system. This includes looking at medication, record keeping, fire safety and complaints. Audits will be carried out at weekends, nights and days. They will include looking at inspection reports and monthly monitoring visits by the Social Care Manager. A number of people who have a learning disability have been recruited and trained to assist in carrying out the audits and lay visitors will also be used. The Manager said that this tool is going to be used in the home January 2007. Fire records showed that staff test the fire equipment regularly to make sure it is working. An engineer services the equipment regularly to ensure it is maintained in good working order. A fire drill is held every six months so that staff and residents know what to do if there is a fire. A fire risk assessment is in place to ensure that action is taken to minimise the risk of a fire starting. Each resident had a fire risk assessment so it had been assessed what the risks are to the individual of a fire starting or if there were a fire and these can be minimised as much as possible. Risk assessments for the premises, using equipment including hoists, staff and moving and handling were in place. These were detailed and regularly reviewed and updated where necessary. An engineer had regularly serviced the hoists, slings and adapted bathing facilities to ensure they are maintained in good working order so they are safe for the residents to be moved in. Staff regularly check the slings to make sure they are not showing any signs of wear and tear that could hinder their ability to support individuals appropriately. Staff test the water temperatures weekly to make sure they are not too hot or cold. The recommended safe temperature is 43 degrees centigrade. Some temperatures including the bath and the wash hand basins in resident’s bedrooms were recorded as between 31 to 35 degrees centigrade, which is quite cool. There was no evidence that action had been taken to adjust the thermostatic valves on taps so that the water is warmer. A Corgi registered engineer completed the annual test of the gas equipment in March and stated that it was in a satisfactory condition. An electrician completed the five-yearly test of the hard wiring in 2003 and stated that it was in a satisfactory condition. An electrician completed the annual test of the portable electrical appliances last December to make sure they are safe to use. The Manager was aware that this is now due again. Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 4 27 3 28 3 29 4 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 X 3 X X 2 x Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 25 No 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. 2. Standard YA33 YA34 Regulation 18 (1) (ac) 7,9,19, Sch 2 Requirement The staff vacancies must be recruited to. Evidence that a satisfactory CRB and the required recruitment checks had been completed for each member of staff employed must be available in the home. Water temperatures must be maintained at 43 degrees centigrade. Timescale for action 31/03/07 31/12/06 3. YA42 12 (1) (a) 13 (4) (ac) 17/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sayer House DS0000062605.V317315.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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