Inspection on 13/02/06 for Selly Oak Road (310)

This inspection was carried out on 13th February 2006.

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

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

Other inspections for this house

Selly Oak Road (310) 13/01/09

Selly Oak Road (310) 24/01/07

Selly Oak Road (310) 17/10/05

Selly Oak Road (310) 24/03/05

Selly Oak Road (310) 28/09/04

Selly Oak Road (310) 17/01/04

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Bryndale Avenue, 41 Flats 13, 14 & 18

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

CARE HOME ADULTS 18-65 Selly Oak Road (310) Selly Oak Birmingham West Midlands B30 1HL Lead Inspector Donna Ahern Unannounced Inspection 13th February 2006 17:00 Selly Oak Road (310) DS0000016962.V283035.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 Selly Oak Road (310) DS0000016962.V283035.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. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Selly Oak Road (310) Address Selly Oak Birmingham West Midlands B30 1HL 0121 459 5199 0121 451 3523 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) Birmingham Focus on Blindness Mrs Barbara Wright Care Home 5 Category(ies) of Sensory impairment (5) registration, with number of places Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That Barbara Wright successfully completes the Registered Managers Award or equivalent by August 2005. 17th October 2005 Date of last inspection Brief Description of the Service: 310 Selly Oak Road is a detached property situated in a residential area of Kings Norton in pleasant grounds and benefits from off-road parking. The rear garden is mostly laid to lawn with a patio area furnished with attractive garden furniture. The home provides care and accommodation to five adults with sensory disabilities. Disabled access to the ground floor of the home is good. There is no lift; therefore residents with a physical disability cannot be accommodated on the first floor. There are ramps, handrails and adapted bathing facilities on the ground floor of the home. Each resident has their own room, which has been decorated according to their individual tastes. The furnishings and decoration of the home are generally of a high standard. There is a lounge, a separate dining room, kitchen, laundry room, toilet and one bedroom on the ground floor. On the first floor there are four single bedrooms, staff sleep-in room/office, bathroom and separate toilet. The home is within walking distance of local shops, transport links to the city centre, leisure facilities and places of worship. Rubery, which has cinemas, shops and restaurants, is a fifteen-minute drive away. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over a late afternoon through to the evening. The inspector met all five residents. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. A number of Health and Safety records and staff records were inspected. The inspector had the opportunity to talk to the manager and two care staff. This report should be read in conjunction with the inspection report of October 2005. What the service does well: What has improved since the last inspection? What they could do better: Records were available of food served these required some minor development and must include a full record of what each resident has eaten so that the home can demonstrate that residents receive a healthy diet and if required, a full audit trail of food served can be tracked. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 6 The window frame in one bedroom was corroded and required replacing. Resident’s needs are changing and some of the residents are slowing down. Staffing levels must be reviewed so that there is sufficient staff on duty throughout the day to meet residents 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. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 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 Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Resident’s current needs are met. The provider must complete a variation application so that the registration certificate can be amended to reflect the current client group. EVIDENCE: There have been no new admissions since the previous inspection and there were no vacancies. The home has an admission procedure, which includes visits to the home as part of the admission process. Residents spoke very positively about their home and the support that they receive from staff. They told the inspector that they are kept fully informed about the running of the home. One resident is over the age of 65 years. In a recent review the home was deemed appropriate to continue to meet their assessed needs. A variation application must be completed and forwarded to CSCI so that the registration certificate can be amended to reflect the category of resident’s accommodated. The organisation plans to reprovide the service in a purpose built home. Plans are only in the very early stages and the organisations said that all relevant parties would be kept informed of developments. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Some development of care plans was required so that a comprehensive support plan is in place, which clearly states how resident’s needs are to be met. EVIDENCE: The manager stated at the previous inspection that there were plans in place to develop the care plans. This work was still in progress. Two of the care plans were briefly sampled. The staff team had consulted with residents about their care and how they want to receive support from staff. This information was in the process of being developed into a support plan for each of the residents. It was really positive that the developments have taken place with evidence of residents being fully consulted including how the information should be written. The care plan must cross reference to risk assessments and relevant policies and procedures. Discussions with residents, staff and the manager indicated that residents are consulted about their wishes, goals and aspirations. One resident spoke about getting a season ticket to go to Aston Villa home matches and a volunteer has now been found to support this activity. This good work must be reflected through the care plan documentation. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 10 A number of risk assessments were in place and some were sampled they gave clear information about the risks to residents and the required action from staff to manage the risks. The risk assessments had been kept under review. The manager was in the process of implementing risk assessments for residents who require support with bathing. Residents said that they had been involved in their recent reviews with the Sight Loss Team and Physical Disability team of Birmingham Social Care and Health. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Minor improvements were required to the record of food served so that there is evidence that residents receive a healthy diet. EVIDENCE: Menus were sampled and indicated that residents are offered a healthy diet. Records of food served were assessed. These required some minor development. They must include a full record of what each resident has eaten so that the home can demonstrate that residents receive a healthy diet and if required, a full audit trail of food served can be tracked. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 12 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): 19, 20 Residents receive a good level of support with their personal care and healthcare needs. EVIDENCE: Health Action Plans, which are personal plans about what a person can do to be healthy, were discussed with the manager at the previous inspection. It was positive to see that much progress had been made on the implementation of these. There was evidence that residents were being fully consulted about the health plans and the manager had consulted with other relevant people so that the information is comprehensive. The manager stated that there was still work to do so that the health action information is completed in full and action required to meet residents health needs, is clearly documented. Progress will be monitored at future inspections. Details of resident’s medication and their consent to receive medication is documented on their care plan. Each resident has a wall-mounted cupboard in his or her own bedroom for medication. The CSCI pharmacist undertook a full inspection of the arrangements for the receipt, recording, storage, handling and administration of medication in March 2005 and found that good systems were in place. One resident’s medication storage and MAR (medication record) was assessed at this inspection and found to be satisfactory. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 13 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 Residents said they feel they are listened to. EVIDENCE: There was a complaint policy and procedure in place. The provider had received no complaints. Residents spoken to said they could talk to staff if they had any concerns or if they are not happy about something. The organisations Adult Protection Procedure was assessed as meeting the required standard at a previous inspection. There was a copy of the Birmingham Multi-agency Guidelines available to compliment the organisations own policy and procedure. Staff had received training on adult protection matters (November 2005). Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 14 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, 30 Residents live in a homely, comfortable and safe environment. EVIDENCE: The home was clean, comfortable and free from offensive odours. All areas of the home were found to be well decorated and generally well maintained. The window frame in a resident’s bedroom required replacing it was corroded. The premises are in keeping with the local community. The organisation plans to reprovide the service in a new purpose built home. Plans were still in the very early stage. Residents have been informed. The organisation had agreed to keep CSCI informed of developments. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 15 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 Staff are well supervised. Some mandatory training required updating so that staff have the required skills and knowledge to support residents. A review of staffing levels is required so that adequate staff are on duty at all times to meet residents needs. EVIDENCE: Rotas indicated and the manager confirmed that there is one staff member on duty on weekday mornings. At all other times there is two staff on duty apart from Saturday’s afternoons/evening when there is three staff on duty to support evening activities. At night there continues to be one staff member sleeping in, on call. The previous report required that staffing levels were kept under review so that adequate staff are on duty to meet residents needs. The morning staffing levels in particular required close monitoring. The manager confirmed that recent reviews had taken place with the placing authority, which had highlighted that resident’s needs are changing and a review of staffing levels was taking place. CSCI must be informed of the outcome. Interactions between residents and staff were friendly and relaxed. Residents spoke very positively about the staff team and manager. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 16 Two staff files were assessed and had details of the application form, references, CRB checks and Identification details. Staff files had minutes of supervision sessions and indicated that six sessions per annum take place. The manager stated that refresher staff training on Infection control, Food Hygiene and Fire safety were scheduled to take place in the forthcoming months. Staff training is also planned on Epilepsy and skin and ageing in response to the specific needs of residents. Staff meeting minutes were available and indicated that practice issues are discussed with the staff team. Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 17 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 The home is well managed. The healthy, safety and welfare of residents is promoted and protected. EVIDENCE: The manager has many years experience working with the client group. She completed NVQ level 4 in August 2005 and was in the process of completing the Registered Manager award. Throughout the inspection process the manager presented as open, positive and inclusive. A number of required records were examined including fire records; health and safety checks and accident records all were in good order with checks and tests completed as required. Residents spoken to said they are asked about their views on the home. Residents knew about inspections and are fully involved in the inspection process. The manager requests that the inspector gives feedback from each Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 18 inspection directly to residents. An action plan has been received by CSCI in response to inspection reports, within the required timescale. The inspector discussed with the manager some of the ways that the organisations Quality Assurance systems could be more formalised as specified in standard 39 of the NMS (National Minimum Standards Care Homes for Adults) Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 19 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 X 2 3 3 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 32 33 34 35 36 2 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X 3 2 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000016962.V283035.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Selly Oak Road (310) Score X 2 3 X 3 X 3 X X 3 X Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard YA6 YA17 YA19 YA24 YA33 Regulation 15 (1)(2) Requirement Care plans required further development. A record of food served must be recorded in full. Timescale for action 30/04/06 21/02/06 30/04/06 31/03/06 31/03/06 Sch4 17 (2) 13 12(1)(a,b) Health Action plans required further development 23 (2)(b) A bedroom window required replacement. 18 (1)(a) Staffing levels must be reviewed. CSCI must be informed of the outcome 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 Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 21 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 Selly Oak Road (310) DS0000016962.V283035.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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