Inspection on 12/02/07 for 11 Station Road

This inspection was carried out on 12th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Station Road 04/09/07

11 Station Road 14/12/05

11 Station Road 12/07/05

11 Station Road 22/02/05

11 Station Road 10/08/04

11 Station Road 15/03/04

11 Station Road 12/08/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Station Road, 11 Kings Norton Birmingham West Midlands B38 8SN Lead Inspector Peter Dawson Key Unannounced Inspection 12th February 2007 09:30 Station Road, 11 DS0000041220.V330247.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 Station Road, 11 DS0000041220.V330247.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. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station Road, 11 Address Kings Norton Birmingham West Midlands B38 8SN 0121 459 8899/2822 0121 459 8149 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Deborah Easy Care Home 9 Category(ies) of Learning disability (9), Physical disability (9), registration, with number Sensory impairment (9) of places Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The minimum number of suitably qualified and competent staff throughout the waking day is 7. The manager is supported by 3 deputy managers, each with responsibility for 2 flats Service users must be aged under 65 years Date of last inspection 14th December 2005 Brief Description of the Service: 11 Station Road is a registered care home, owned and managed by SENSE, which is a voluntary organisation supporting people with dual sensory impairment and associated disabilities. It is located in Kings Norton, Birmingham and is close to a variety of shops, public transport and community facilities. The home comprises of 3 flats with two bedrooms, and 3 flats with one bedroom. All flats are self-contained and each bedroom has an en-suite bathroom. The home also provides a communal lounge and kitchenette and a separate laundry room. There is a small staff office on the ground floor and a staff sleep in room, which is currently also being used as a working office on the second floor. There is a large communal bathroom on the ground floor, which would be suitable for someone with additional physical needs. The current service users do not use the bathroom. There is a large, landscaped garden to the rear of the building with features to aid access for people with sensory disabilities. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day by one inspector from 9.45. am. – 4.45. pm. The Registered Manager was on leave and the inspection carried out with the Assistant General Manager responsible for the home. A pre-inspection questionnaire was completed by the Manager prior to the inspection and provides a basis for some information in this report. Due to limited verbal communication, it was not possible for residents to express their views to the inspector but time spent observing care practices and interactions and discussions with staff gave a general picture of the lives of residents. It was not possible to speak with relatives or other professionals at the time of this inspection. All 7 residents were seen in their individual accommodation and there was an inspection of the environment. Records relating to the inspection process were examined and included care plans, risk assessments, medication records, coordinators files, staff files and rotas and other documents relevant to the inspection process. All documents relating to care planning, risk assessments and medication are kept individually in residents flats, so were seen individually when inspecting each flat. The last inspection of this home was on 14th December 2005. The fees for residents at Station Road are from £2,196 - £4,797 per week based upon assessed needs. What the service does well: This service has brought together 7 current residents who had previous group home placements and all exhibited extreme challenging behaviours. All are accommodated in individual self-contained flats – there are 3 with a single bedroom and 3 with two bedrooms. The incidence of challenging behaviours over time have diminished dramatically indicating a successful formula for meeting the very complex needs of this group. The standard of accommodation is good with spacious flats and good selfcontained facilities. All include lounge/dining area, bedroom, kitchen and ensuite area with bath/shower. The well-laid garden area compliments the indoor facilities. The complex and high dependency needs of residents are understood by a committed and experienced staff group. Allocation of staff is individual to each Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 6 person. Care planning records provide good detailed information for staff in the actions to be taken to meet needs. All residents have a schedule of individual daily activities with an accent upon accessing community facilities. Three vehicles are available for transport with adequate numbers of staff drivers, approved/available. What has improved since the last inspection? What they could do better: Some staff training in Fire Safety has taken place but all staff must have regular training. There are shortfalls in many areas of statutory training for staff this must be addressed. All staff must received moving & handling training annually, not every 3 years. Toilet seat must be fixed in bathroom area. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 7 Protocols for PRN medication must be dated. Staff should all wear personal ID symbols at all times. All residents should be weighed monthly. The review of the management arrangements for the home should be finalised and CSCI informed of the arrangements. 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. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1- 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information is available to make an informed decision about admission to the home. EVIDENCE: There is a statement of purpose and service users guide in the home available for visitors and a copy of the statement of purpose in all flats. Additionally the home produces a colour leaflet with photographs summarising the facilities available at Station Road, this is simple but helpful and informative. There is adequate information to allow an informed decision to be made about admission. There have been no new admissions to Station Road for sometime. A summary of the admission process is in the statement of purpose and SENSE has a Referral and Information Manager able to offer support and guidance to prospective residents. Prior to admission the manager would complete a comprehensive assessment of need and gradual introductions to the home arranged. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6 - 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Considerable work has been input to improve care planning information and completing risks assessments for all areas of activity. These are now satisfactory. There was evidence of residents making decisions and choices about their daily lives. EVIDENCE: A lot of work has been done since the last inspection to update care plans and risk assessments and to include control measures and level of risk in the risk assessments. This work has been completed and there are regular reviews. Absence of cultural needs was evident but this has and is being addressed in relation to a resident without relatives/visitors, efforts are being made to identify social and cultural activities which are appropriate for him. There has been staff discussion and research in relation to the specific cultural needs of this person. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 11 There had been a vacancy following the Practice Development Worker leaving at the time of the last inspection (1 year ago) but the post was filled and some positive work done. The PDW has, in fact recently taken maternity leave and replacement being sought. Meanwhile staff are reviewing and updating information relating to all aspects of care planning. A typical care plan seen in one flat outlined daily routines, best/worse days, preparing breakfast independently, physical intervention risk assessment, morning, evening and night routines, cooking sessions. The fact that the person liked to go out at any time and in all weathers was recorded and reflected in her activity programme, detailed information contained, for instance when going to the pub that she liked 2 Bacardi Breezers. The resident has a tactile card system which she initiates and makes daily choices. The activity programme was checked and there was virtual 100 planned activity taking place. Planned activity for a resident included a weekly slot for writing letters to family this reflected the need for regular weekly contact with family. Core team meeting reviews were seen and contained relevant information about inputs and outcomes. They were signed by all present. Risk assessments showed balanced decisions made in relation to internal and external activity. Participation in an activity or daily living were accompanied by a risk assessment. Station Road, 11 DS0000041220.V330247.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): Standards 11 – 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for personal development are identified and action taken to extended quality of life with a range of internal and community based activities. Meal provision is individual and good, with cultural needs adequately considered. EVIDENCE: It was identified in the last 2 inspection reports that too many planned activities were cancelled for several reasons including lack of drivers or staff. Progress has been made in this area and virtually all activities tracked had been undertaken. The number of drivers has increased and is adequate. Additionally the majority of residents in this home use public transport and for some is the preferred choice. There are never occasions when activities do not take place as a result of lack of transport. Three vehicles are constantly available for transport purposes. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 13 Activity programmes include a range of external activities throughout the week on an individual basis, they range for services accessed centrally at SENSE facilities to a wide use of community facilities, including swimming, rock climbing, rambles, cinema, pubs, shopping, church. Some resident require to simply be out in the open air and enjoy daily walks. Family contacts are promoted. Some contacts are very regular others less regular due to distance, circumstance etc. One resident does not have family contacts. This is being further pursued as is also the possibility of an advocate of the same cultural origin. The sexual needs of a resident were known to staff and reflected in care planning information. Food is provided individually in each flat. Most residents are able to express daily preferences. There is shopping on an individual basis, food cooked by staff with assistance where possible form the resident. An issue concerning the specific cultural food needs of a Sikh resident was identified in the last report. In the absence of guidance from relatives staff have discussed and researched basic cultural food options and providing these in consideration of the residents responses and preferences. There are no rolling menus. All food is prepared individually for each resident, there is no communal dining area. Station Road, 11 DS0000041220.V330247.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): Standards 18 - 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Health care monitoring systems were in place apart from regular weighing of residents which has been subject to 2 previous requirements. The reduction of incidents of challenging behaviours is to the credit of staff. Some aspects of the medication system have improved since the last inspection. EVIDENCE: Observations and records showed that personal care is provided in the privacy of bedrooms. Residents were seen accessing their bedrooms in their flats from choice. Closing doors meant that staff were not allowed and that was accepted/respected. All flats have en-suite facilities with bath/shower allowing exclusive single use in the privacy of their own accommodation. Health care records were sampled and monitoring of specialist health care services were well recorded with outcomes. Regular weighing of all residents was a requirement of the last report. In one instance seen a person had not been weighed for over 2 months. It is Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 15 important to monitor weight that can be a sign a person is unwell, if they are unable to verbally communicate. None of the residents present concerns in relation to being underweight at this time. Two residents had been overweight, professional advice sought and with a more healthy diet 2 residents had each lost 2 stones in weight. Staff have received some training in health eating regimes and these have been positively applied with good results. All residents (there are presently 7) are high dependency and all have virtually 1:1 staffing. All have a severe learning disability and varying levels of hearing/sight. All have no speech or very limited verbal communication. Communication is by means of BSL (British Sign Language), Hand over hand or by objects of reference. All have communication symbols they use on an ongoing basis. All staff are required to wear personal identification symbols. It was noted during the inspection that an agency member of staff was not wearing one. It is important that all staff wear clear ID at all times. All 7 residents in this home have previously had severe challenging behaviours, exhibited in former placements and initially in this one. Movement to Station Road has meant that rather than small group living, which clearly exacerbated the presented behaviours, all are now living in their own flat or a maximum of 2 person flats with 1:1 staffing and this has been immensely successful. Challenging behaviours have reduced in severity and regularity – in fact there have only been 2 instances of challenging behaviours in the home in the past year. Living alone has clearly reduced the pressures upon residents. This is a tremendous success. There was evidence of a range of health professionals involved in residents care, including services from specialist learning disability nurses. Records seen also showed that at least annual health checks had been carried out as required. The medication system and records were inspected. All staff administering medication have had accredited training with Boots Chemists (suppliers) and additional assessment for competence in accordance with SENSE procedures. A requirement to re-locate a medicine cupboard for greater safety has been completed. Creams and ointments are now dated when opened and discarded within required timescales. Medication prescribed PRN (as required) appear to all have written protocols, although some were not dated and this needs to be done. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 16 Medication errors have been notified to CSCI since the last inspection, relating to medication not given. These have been investigated and appropriate action taken by the service. Medication is kept separately in each persons flat in a secure locked cupboard. MAR (Medication Administration Records) are also kept separately in each flat. Records sampled had been completed accurately and consistently Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 17 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): Standards 22 – 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Physical intervention incidents are now all reported to CSCI. Some staff training is required in the protection of vulnerable adults. The complaints procedure is in place and satisfactory. EVIDENCE: A requirement of the last report to notify CSCI of all instances of physical intervention used by staff and relevant details, has been met. – It was pleasing to see that only 2 incidents of challenging behaviour requiring interventions had occurred since the last inspection over 1 year ago. Only 2 staff have not received training in NCI training. This is being arranged. Annual refresher training for staff had either taken place or was planned. SENSE has notified CSCI of the outcomes of an investigation referred under Vulnerable Adults procedures which was outstanding at the time of the last report. Recently CSCI were notified of an incident correctly referred under Vulnerable Adults procedures by the home and a member of staff suspended as part of the required procedure. This is being investigated and CSCI will be informed of the outcome. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 18 Eight staff have not received training in the protection of vulnerable adults and this must be provided. The complaints procedure is available in the home and in relevant format. This is available also to all visitors. Two complaints have been received from neighbours since the last inspection and dealt with by the home. They relate to a security light and car parking. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 19 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): Standards 24 – 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good standard, comfortable, homely and safe environment. Facilities are exceptionally good with self-contained accommodation in 6 flats. Residents have the facilities and equipment necessary to maximise independence and meet their needs. Proven results in providing self-contained accommodation with 1:1 staffing meeting the needs of high dependency residents with challenging behaviours. EVIDENCE: This is a well-presented complex of flats comprising 3 single and 3 bedroom flats. Each is self contained and provides spacious lounge/dining, kitchen, bedroom and en-suite bathroom facilities all with baths/showers. The whole building is self-contained but allowing access to each flat from inside the complex. There is additionally a large communal dining/recreation room and kitchen and also separate toilet and communal shower area (presently Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 20 unused). The building is relatively new, well furnished and decorated to a high standard. It is owned by Accord Housing Association and is well maintained. Requests for repairs actioned swiftly. The home is well furnished and the only aspect identified in relation to furnishings was the replacement of settees in one flat – these are apparently on order. In one of the flats a toilet seat was not fixed and unsafe. This must be secured immediately. There is also an excellent and well planned communal garden area which is private and safe. Access is good/level from the building, there is good seating and other facilities allowing ongoing use during the summer months. There is also direct access from some flats. The home is adapted to meet the needs of people with a sensory impairment and include relevant symbols, objects of reference etc. A requirement in the last report to provide a resident with declining mobility needs with a specialist adapted bathing facility has been met. All areas of the home were clean and hygienic on this visit. Infection control equipment was readily available. Domestic hours are provided and standards are good. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 21 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): Standards 31 – 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A committed staff group providing a specialist service to a small group of residents with complex needs and providing positive results. Most areas of statutory training for staff are required and there is a training plan in place that perhaps should be further reviewed to ensure crucial training takes place sooner. Staff recruitment procedures and files were satisfactory. All staff receive regular supervision. EVIDENCE: There was one requirement in the last report relating to staffing. That was to provide staff training in all areas of statutory training need and to provide a training plan forwarded to CSCI. There has been staff training but there are still shortfalls in this area. Shortfalls varied between the 3 staff groups but most areas of statutory training are required still for some staff. This was discussed, accepted and agreed during the inspection. There is a training plan Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 22 in place with allocated dates for training and Managers need to ensure that vital training is provided/brought forward in some areas to ensure safety of residents. It was noted that staff received only 3 yearly updated training in moving & handling and this should be on an annual basis. There are 3 managers each responsible for two flats each. Staff are allocated to a specific group. Residents in single bedroom flats have 1:1 staffing, those in 2 bedroom flats have one or two staff. During the waking day there are always 7 staff on duty. At the time of this inspection there were 7 people in residents this equating to 1:1 staffing for all residents. There are presently 6 staff on duty at night – one for each flat, although this is being reviewed and may be reduced to 5. The dependency levels have diminished with a dramatic decrease in the number of incidents of challenging behaviour. This staffing level would appear adequate. It is a condition of registration that a minimum number of 7 staff are provided during the day and a minimum of 4 staff throughout the night. These conditions relate to full occupancy (9) and are met. There are presently over 40 staff employed (including bank staff). All are allocated over the 3 managed units of 2 flats each. Staff are allocated to specific residents and therefore have an in-depth knowledge of their needs and experience in dealing with any potential difficult situations. This intense and specific allocation of staff has undoubtedly reduced the number of incidents of challenging behaviours and certainly improved quality of life for residents. There are presently 2 staffing vacancies. Some bank staff are used who know the residents and able to provide continuity. Agency staff are reduced to a minimum because of the need to have prior and specific knowledge of the complex needs of residents. An agency member of staff on duty was spoken to. She had prior knowledge of some residents and was briefed in detail about the needs of others prior to engaging in care provision. This person showed knowledge and competence in providing a service to this group of residents with specialist and complex needs. Other permanent members of staff on duty were spoken with, some have worked with individual residents in this home over a period of years and clearly formed very positive relationships with them. This enabled them to extend and improve residents independence whilst offering a supportive, positive and professional service to this group of residents with complex needs. A sample of 2 staffing records were seen. Both contained all required information and documentation required under Schedule 2. CRB checks had been obtained prior to employment. Information relating to agency staff was inspected and similarly, all information was available relating to their Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 23 background, experience and training. Supervision files were inspected and this had been provided at the required intervals. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 40 - 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Record keeping, policies and procedures seen protect the interests of residents. Statutory training is required in several areas and should be provided as soon as possible. There is close and effective oversight and management of the home by SENSE Managers. EVIDENCE: The Manager has been employed in the home since prior to the last inspection and a requirement made to make application for registration. This has now Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 25 been completed and the manager was approve by CSCI as the Registered Manager in June 2006. She was on leave at the time of this inspection so it e was not possible to objectively assess her management style and skills. It was, nevertheless clear from discussions with other staff, the Assistant General Manager, from records and observations that the home appeared to be well run and that progress has been made in several areas of service provision. A requirement of the last report was to review the management arrangements in the home to ensure the Registered Manager has responsibility and accountability for all of the flats within the SENSE organisational structure. – This is still being finalised and the outcome will be reported to CSCI as soon as possible. This is a complex area. The Registered Manager is supported by two unregistered managers (one presently on maternity leave), each supervising two flats. There are high staffing numbers and inherent management overview is required. The Registered Manager has access to all documentation, staff and all parts of the home – there is transparency. Other issues concerning pay, grading and management systems are presently being considered. CSCI will be informed of the final arrangements in the near future. A requirement to provide fire training for staff has been addressed in part, but still there are 4 people who have not received any fire training. Moving & Handling updating training should be provided on an annual basis. Staff training needs are mentioned previously in this report and cover most areas of statutory training requirements. These must be prioritised and carried out swiftly. The Fire Officer visited on 18/10/06 and no requirements were made. There was positive discussion concerning the many false alarms due to the smoke alerts in the kitchen areas (burned toast). He was able to give positive advice and an agreed procedure documented. Management arrangements by SENSE for the home are good. The Assistant General Manager meets monthly with the Registered Manager and 2 unregistered managers. Regulation 26 visits are carried out unannounced on a monthly visit and copy reports left in the home and sent to CSCI. Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 x 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 4 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 1 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 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 2 2 X X X X 3 3 2 2 Station Road, 11 DS0000041220.V330247.R01.S.doc Version 5.2 Page 27 YES 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 3 4 5 Standard YA20 YA27 YA32 YA42 YA43 Regulation 13(2) 23(2)(c ) 18(1)(c ) 13(5) 10(1) Requirement PRN protocols must be dated. Toilet seat in bathroom area identified must be fixed. All staff must receive statutory training as required. Previous requirement not met. All staff must receive Moving & Handling updating training on an annual basis. Outcome of the review of the management systems in the home must be notified to CSCI when finalised. Timescale for action 28/02/07 13/02/07 31/05/07 31/03/07 31/03/07 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 2 Refer to Standard YA19 YA33 Good Practice Recommendations All residents should be weighed at least monthly. Staff should wear personal symbols at all times. Station Road, 11 DS0000041220.V330247.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 Station Road, 11 DS0000041220.V330247.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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