Inspection on 10/08/07 for St Albans Road (38)

This inspection was carried out on 10th August 2007.

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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Albans Road (38) 01/02/08

St Albans Road (38) 27/06/06

St Albans Road (38) 14/12/05

St Albans Road (38) 11/08/05

St Albans Road (38) 10/03/05

St Albans Road (38) 18/05/04

St Albans Road (38) 14/02/04

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 St Albans Road (38) Moseley Birmingham West Midlands B13 9AR Lead Inspector Jane Rumble Key Unannounced Inspection 10th August 2007 09:00 St Albans Road (38) DS0000016928.V348123.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 St Albans Road (38) DS0000016928.V348123.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. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Albans Road (38) Address Moseley Birmingham West Midlands B13 9AR 0121 449 3615 F/P 0121 449 3615 laura@trident-ha.org erikal@trident-ha.org.uk Trident Housing Association 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) Miss Karen Clark Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Karen Clarke will attend a course on managing challenging behaviour of at least 3 days in duration. The course syllabus should be approved by the NCSC Karen Clarke should complete her NVQ level4 in Management of care by June 2004 10th January 2007 Date of last inspection Brief Description of the Service: St Albans is a purpose built detached, two storey building situated in a residential road in Moseley. The service accommodates six service users who have a learning disability, and a physical disability. Some service users have a behaviour that can challenge. The service is well situated for local amenities. There is a range of shops and Kings Heath shopping centre is close by as is Moseley village. The premises consist of six bedrooms with en-suite level access shower facilities. There is an open plan kitchen and dining room with good access for people with physical disabilities. Two communal areas are available one of which is utilised as a quiet room furnished with beanbags and easy chairs. There is a snoozelen room with a range of sensory equipment including fibre optic lights and lights. On the ground floor there is a communal bathroom that has a jacuzzi bath. The first floor is accessed via a passenger lift, with controls at a level people using a wheelchair can access. There is an office on the first floor and a sleep in facility is on the ground floor. This does not include separate staff bathing or toilet facilities. A separate laundry room is located at the rear of the premises. The rear garden has a patio area, which has recently been levelled and re-laid. The back garden is fenced and affords some degree of privacy. There is limited off road parking available. Information is made available using pictures and symbols to the people who use the service. CSCI reports are made available in the Home for anyone wishing to use the service. Weekly fees are £810 per week inclusive of a weekly contribution for toiletries and an annual payment towards the cost of holidays. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit took place on one day and the home did not know we were coming. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the visit taking place a range of information was gathered including notifications received from the home and copies of the monthly visits to the service by the provider to look at how well the home is performing. This information has been used within this report Two people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. All people who lived at the home were met. Due to their communication needs people who live at the home were not able to tell the inspector about what they thought about the service they receive. Some time on the inspection was spent observing staff interactions with residents. Discussions with two staff, service manager, operation manager and the acting Manager took place. What the service does well: Residents live in a home that has lots of space and aids available so that they live in a home that is suitable to meet their needs. Pictures and symbols are used a lot in the home to help people living there understand things easier. People living at the home are able to move around the home freely without restrictions so they can spend time on their own or with others. Lots of checks are done before some one comes to work at the home so that only people suitable to work with vulnerable people are employed. Staff at the home help residents to look after their money safely so that they do not loose it or have it stolen. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 6 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. St Albans Road (38) DS0000016928.V348123.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 St Albans Road (38) DS0000016928.V348123.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 would have sufficient accessible information to enable them make an informed decision about whether they wanted to live at the home. EVIDENCE: Currently there are no vacancies; people at the home have lived there for a number of years. There is a Statement of Purpose and a Service User Guide available that provide information about the home and the facilities available. Both of these documents include pictures and symbols to help make the information easier to understand. These were on display in the home so people living there could read them if they wanted to. An assessment of a prospective residents needs would be done before any one new moved into the home to make sure that the home could met their needs. St Albans Road (38) DS0000016928.V348123.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 and 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Although there is a care planning system and risk assessments are completed these do not provide staff with all the information they need to meet peoples needs consistently and safely. EVIDENCE: Each person has an individual care plan. Two people were case tracked and their care plans were looked at in detail. Care plans need to be developed so that they contain sufficient detail so that staff know what support to offer people. Care plans provided some information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs but further detail was needed. They did not contain St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 10 any information about how to support the person with their sexuality or sexual orientation. Where a person has behaviours that challenge not all of these behaviours are included in the care plan with guidelines available for staff to enable them to manage the behaviour safely, in a manner that respects the individual. Some strategies need reviewing to ensure that they are still appropriate as they were last reviewed in 2002. In addition daily records did not reflect they were being followed. For example a strategy for one person referred to offering a positive interaction every 5 minutes. Daily records did not show that this was happening and observations on the day did not evidence that this was happening. Information in the care plans would benefit from being more person centred for example to include more details about peoples cultural needs, food likes and dislikes and the activities they enjoy doing. This will help to ensure staff provide support in the way people prefer and need. It is pleasing that this has been recognised by the organisation who are starting to work on person centred plans for people. Each person’s records included individual risk assessments. These had been regularly reviewed, but clearly not thoroughly. These stated how staff are to support the person to reduce the risks from things such as aggression, road safety, seizures, hot drinks, accessing the community and choking. Risk assessments sampled at this visit required further work to demonstrate that staff have accurate information to manage risk in a responsible way. For example: • One persons risk assessment for a medical condition stated that he should be left to bathe unsupervised, yet a risk assessment for bathing states that he should be supervised. This inconsistently means that staff have conflicting advice to follow that potentially places the person at risk of harm. • Risk assessments made statements about a risk but did not include details of risk control measures for staff to follow to help the person stay safe. A risk assessment for a persons behaviour of running off in the community stated that the risk control was road safety but gave no detail of how to support the person and what actions to take to keep them safe. • An incident of intimate contract between two people was reported to Social Services. There was a record that following this a risk assessment had been completed and implemented. There was no evidence that this risk assessment existed. It was evident from sampling risk assessments that staff need further guidance to provide them with clarity about the purpose of a risk assessment St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 11 and when to complete them. In some cases a risk assessment had been written for medical conditions instead of a care plan. There is evidence that people who live in the home are supported to make some choices about their daily life. Staff were observed offering people choices about what they wanted to drink and whether or not to take apart in an activity or attend their day centre. These choices were observed to be respected. However the inspector also observed that one resident was indicating that they would like a drink by reaching out for a cup, but the member of staff told him that he had just had one and did not offer him a drink. This is poor practice and does not indicate that all staff are aware of individuals preferred communication. It is good practice that one person has a communication book that he is supported to use to enable him to communicate with staff about his needs and choices. It was noted that this book needs to be updated to reflect the current staffing in the home. Due to residents limited communication skills residents meetings do not occur, however one person attends the organisations tenants meetings regularly. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Leisure and recreational opportunities are limited so that people do not experience a varied and interesting lifestyle. EVIDENCE: People living at the home attend day centre opportunities Monday to Friday, although peoples wishes to attend or not on a daily basis are respected. Outside of attending day opportunities there are limited activities available for people to take part in. Activity records do not show that people have the chance to take part in regular out of house leisure and recreational activities. Where there are records available it is not clear whether the person enjoyed the activity or not. This does not support the people living at the home to become part of the local community. Individual’s financial records do not show expenditure on activities. Staff spoken to also stated that activities available St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 13 for people outside of the home are limited. Although there is a holiday booked for three people in the near future. People living in the home were clean and well presented in clothing appropriate to their age, the weather and gender. One person chooses not to follow their religion and culture, in terms of food eaten, prayer and clothing. This is recorded in his care plan with evidence that this has been discussed and agreed with his parents. Although it was recorded that the family would like him to have opportunities to eat appropriate cultural food and attend the temple. Records available did evidence that he had attended the temple with staff support but there was no evidence that he had the opportunity to try appropriate foods. Records and discussions with staff show that people are supported to maintain relationships with their families on a regular basis with family birthday dates available so that residents can be supported to celebrate them. Families are welcome to visit at any time. There was evidence that staff had failed to support people to explore opportunities to have personal and intimate relationships. On more than one occasion two people were seen having intimate contact. Staff had made the assumption that this contact was abusive and taken steps to prevent them having time together. There was no exploration if the contact was consensual or abusive so that appropriate support could be given. There is a three-week rotational menu in place. Menus are written documents and people living in the home would not understand the information in them. Consideration should be given to producing in a format that residents can understand so they can make choices. The menu shows that people living at the home are offered a varied and nutritious diet. However there was no evidence that one person is given regular opportunities to eat culturally appropriate food. One person requires a special diet due to medical reasons. With the exception of the person who requires a special diet records of food eaten by individuals are not maintained in enough detail to evidence what people are having. There were adequate supplies of food in the home including fresh fruit and vegetables. Residents were observed helping themselves to fruit and were clearly aware of where different foods were kept in the home. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living at the home cannot be confident that their health care needs are met in a way that promotes their health and welfare. EVIDENCE: People have a detailed record of how to support them with their personal care and any routines that may have. This information is useful in enabling staff to support people in the way they prefer including gender specific care for personal and intimate care task. However the plans seen gave information about the person’s routines for days that they attend the day centre only. Staff would benefit if these were expanded so that they also have information about the persons preferred routines for days where they do not go out to the day centre. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 15 Each person has Health Action Plan (HAP); this is an individual plan of what the person needs to do to stay healthy. These recorded that people are given the opportunity to attend doctors, dentist and chiropodist as required. Some people need staff support to maintain a healthy weight. It was disappointing that weight charts seen were vague and do not provide useful information. For example they stated ‘just over 16 stone’. This does not help staff to see if a person is gaining or loosing weight so that they can support the person appropriately. Another persons weight chart showed that he had gained two stone in a month. There was no evidence that staff had taken any action to find out the cause of this significant weight gain. One person has a significant medical condition that requires him to have a strict special diet. Staff have consulted with relevant health care professionals to provide them with specific guidelines about how to support the person. It was very concerning that records made demonstrated that his diet was not being followed consistently and the record was not always completed to show what he was eating. This area of serious concern had not been noticed or addressed by the staff or acting manager at the home. This practice places this person’s life health and welfare at serious risk. This was discussed in detail with senior managers at the time of the visit. One person’s file refers to the risk of choking but does not provide staff with information about high-risk foods that should be avoided to minimise the risk of choking. Another persons file referred to him receiving medication to treat constipation but there was no information in his HAP that he was constipated or a care plan available so staff knew how to support him in this area. The home uses a monitored dosage medication system and stock control procedures are in place. There are storage facilities available so that medication is kept safely. Care staff administers medication but have to be assessed as having the skills and knowledge to do this first. Where resident are prescribed PRN ‘as required ‘ medication there are protocols in place so staff know how much to give and when. However it was noted that PRN medication is only signed when given, with no record of when it is offered but refused. Medication administration records were generally well maintained. There were however some examples of where medication had not been signed as administered or a code entered to record the reason for none administration. This means that staff cannot evidence that the person has taken their tablets. St Albans Road (38) DS0000016928.V348123.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 adequate This judgement has been made using available evidence including a visit to this service. Staff recognises and respond to the risk of abuse but need to be better at following guidelines to ensure that residents are safeguard from the risk of harm consistently. EVIDENCE: The home has a complaints procedure, which includes pictures and symbols to make the information easier to understand. Residents at the home have limited communication skills and rely on staff to know their needs and know about things that make them unhappy or upset. There have been no complaints received by the home or CSCI since the last inspection. There have been two incidents since the last inspection that has been reported to Social Services under the muliti agency vulnerable adults procedures. One of these incidents had been investigated and a number of actions agreed to ensure the person was safe guarded from, as discussed in the health care section of this report. It is concerning that these were still not being consistently followed. The second incident was reported to Social Services when staff found two people together engaging in intimate contact, as discussed under the life styles section of this report. The homes records show that this was reported as a St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 17 vulnerable adults matter and state that as a result a risk assessment has been implemented. However, staffs spoken to were unaware of the existence of this document and it was not available on the persons file. Care staff spoken to were aware of the action to take in the event of an allegation being made and would report it to a senior member of staff. Residents are protected by the homes procedures for managing their personal monies. A record of money held on behalf of residents is maintained; receipts are available for all expenditure and two staff checks daily that money held is accurate. St Albans Road (38) DS0000016928.V348123.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, 28, 29 & 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. People live in a clean well maintained home that meets their individual needs. EVIDENCE: The home was clean, tidy and generally well maintained. There has been some recent refurbishment and redecoration so that people live in a pleasant home. People have their own bedroom that includes an en-suite WC and shower facility. Some people choose to lock their bedroom doors if they want so that they can maintain their privacy. There is a choice of communal space available so that people can choose to spend time with others or on their own. Rooms reflect the taste and interest of people living there and there are a number of photographs around the home of them taking part in some activities. There is an assisted bathing facility available in the home so that people can choose to take a bath if they wish. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 19 The laundry is big enough so that people can take part in their own washing with staff support if they want. It was noted that the laundry has a sluice sink but there are no hand wash facilities available for staff to wash their hands in this area. This creates the risk of cross infection. St Albans Road (38) DS0000016928.V348123.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): 32, 34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The training, development and supervision of staff is inconsistent and staff lack leadership so that they do not have all the guidance and skills they need to meet residents needs. EVIDENCE: The home have not had a stable staff team for some time, there is a high reliance on the use of agency staff which means that residents do not receive care from people who know them well. The home has just recruited two new staff members and a manager, which will mean that the home will need to use less agency staff. It is good practice that staff shift plans are used so staff know what their responsibilities will be throughout the shift. Staff working at the home also do the shopping, cleaning and cooking so they can be busy. Staff rotas show that the staff team have a good balance of both male and females so that residents can choose to receive care from staff of the same or St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 21 different gender. However the culture of the staff team does not reflect the culture of the residents living in the home. Consideration should be given to recruiting some more staff to reflect the culture of the residents. Files sampled and staff spoken to show that the home makes checks to ensure that prospective employees are suitable to work with vulnerable adults. Observations on the day show that some staff have positive relationships with the people living at the home and seemed to have a good understanding of peoples needs. One resident seemed very excited when a member of staff arrived on duty. It was noted that not all staff on duty used makaton despite this being this person’s first language. Records were not available in the home to show that staff have received all the training needed to meet peoples needs for example autism awareness, managing challenging behaviour, makaton, epilepsy, renal dysfunction and swallowing difficulties. Or had completed mandatory training in first aid, fire training, manual handling, and food hygiene, health and safety and adult protection. In addition the home does not provide new staff with specialist training in meeting the needs of people with a learning disability (LDAF). The home has an induction-training programme to induct people into their role. However one member of staff felt that the induction programmes could be improved so they were more prepared to work at the home. Staff have supervision to support them in their role. It was noted in one persons file that actions agreed had not been followed through which means they may feel unsupported. Staff commented that the lack of a designated manager and the high reliance on agency staff has meant that staff do not always feel supported within their role. Regular staff meetings occur and these also demonstrate that staff do not always feel well supported or that residents are benefiting from a well motivated staff team. St Albans Road (38) DS0000016928.V348123.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): 37,39, 42 & 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The absence of a knowledgeable and competent manager means that residents do no benefit from living in a home that is run in their best interest. EVIDENCE: The home has not had a registered manager for some time which means that resident and staff have experienced a lack of leadership and direction. Staff spoken to said the lack of management stability has contributed to tensions within the staff team. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 23 Some records needed updating and reorganising to show that the residents benefit from living in a well run home. Most health and safety checks in the home are occurring at the required frequency so that the equipment, facilities and services are safe and well maintained. The most recent fire officer report indicated that need for some remedial work to the ceiling in the dinning room. Discussions with the operation manager and records available in the home did not evidence that this work has been completed. Weekly test of the fire system are made but it is disappointing that test of the emergency lighting system is not occurring often enough to make sure that in the event of an emergency they would work. During the inspection there was a fire drill. The actions taken by staff were not adequate to be confident that in the event of a real fire residents would be protected by staff actions. Monthly visits take place by a representative of the organisation to comment on the quality of the service provided. Records of these were in the home but is disappointing that many of the issues identified by the inspection had not been noticed. There is not a formal quality assurance system to encourage the development of the service. Residents are unable to comment formally on their views of the service provided and are dependent upon the home taking proactive steps to monitor its own quality. St Albans Road (38) DS0000016928.V348123.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 X 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 1 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 2 X 2 X X 2 2 St Albans Road (38) DS0000016928.V348123.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. Standard YA19 Regulation 15(1) Requirement Behaviour guidelines must be current and include details about the behaviours that are exhibited and information about what staff should to do manage these. Staff must follow guidelines provided by health care professionals so that people’s health care needs are met. Staff must have the knowledge and skills so that if the event of a fire they know how to safeguard people living in the home. There must be evidence that staff have received training so that they can meet the needs of the people living in the home and communicate with them in their preferred language. Care plans must describe how to meet residents health care needs so that staff have sufficient guidance to meet needs Risk assessments must provide details of risk control measures so that staff know how to keep people safe Staff need training in equalities and diversity so that they can DS0000016928.V348123.R01.S.doc Timescale for action 30/09/07 2. YA19 12(1) 31/08/07 3. YA42 23(4) 31/08/07 4. YA32 18(2) 31/08/07 5. YA19 15 31/08/07 6. YA9 13(4) 31/08/07 7. YA35 18(1) a 31/10/07 St Albans Road (38) Version 5.2 Page 26 8. YA20 13(2) 9. YA6 14(2) 10. YA12 YA13 16(2) n 12(1)&(2) 16(2) j YA30 11. 12. YA23 meet the individual needs of the people living at the home Medication records must accurately record when a medicine has being given or the reason for none administration Care plans, risk assessments and behaviour guidelines must be reviewed regularly to make sure that staff have up to date information Residents must be given regular opportunities to take part in both in and out of house activities so that they live an interesting life Measures that are put in place following a vulnerable adults referral must be followed Hand wash facilities must be provided in the laundry to reduce the risk of cross infection 11/08/07 28/09/07 31/08/07 10/08/07 30/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Care plans are developed to include information on how to meet needs arising from residents sexuality and sexual orientation It is recommended that records of food actually eaten by residents in the care home be maintained in good detail. Staffs are provided additional training in managing risk and writing risk assessments. Daily routines should be expanded to include the persons preferred activities for days they do not attend day centres. Evidence should be available in the home to demonstrate the training staff have done. DS0000016928.V348123.R01.S.doc Version 5.2 Page 27 2. 3. YA17 YA9 4. 5. YA18 YA35 St Albans Road (38) 6. 7 YA36 YA39 Where measures are agreed in a persons supervision session then these should be followed so that they feel well supported A quality assurance system must be in place to encourage the development of the service. St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 28 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 St Albans Road (38) DS0000016928.V348123.R01.S.doc Version 5.2 Page 29 - 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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