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Inspection on 14/12/05 for 11 Station Road

Also see our care home review for 11 Station Road for more information

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users were well presented, dressed appropriately to their age and gender. Service users are well supported in their daily living tasks without losing their independence. The staff on duty were observed to support service users competently with patience and respect. Throughout the inspection the Manager was open and responsive to suggestions for improvements. The flats are homely in style, and decorated and furnished to a good standard.

What has improved since the last inspection?

The statement of purpose has been updated as required at the last inspection and now contains all the required information. Risk assessments have been further developed to include good detail to show clearly that they have been reviewed. Care plans continue to be reviewed and developed, but require further development. A recent audit of activities undertaken by the Manager indicates that the home has gone from 60% of planned activities taking place to 80%. Staff have recently attended a training session on menu planning and portion control. Staff who required it have received training in physical intervention. Epilepsy guidelines are now available for staff. These include descriptions of a seizure and the action staff must take in the event of a seizure occurring. Some internal decoration has taken place since the last inspection making the home a more pleasant place to live. Progress has been made on the recruitment of new staff. Staffing hours have been increased giving more flexibility to respond to service users needs. The appointment of a new manager has brought some much needed stability to the home.

What the care home could do better:

Care plans must be signed, dated and reviewed at least six monthly. The care plans must detail how any cultural needs will be met. Any guidelines in place must also be kept under review. Cultural and/or religious needs need to be taken into account when planning menus. The use of `as required` medication requires improvement to ensure service users receive the medication they need. Further development of the homes healthcare monitoring systems were required regarding weight so that the home can evidence that the service users needs are properly monitored and kept under review. CSCI must be notified of all occurrences where physical intervention is used to ensure service users are protected from risk of abuse. One service user has not been provided with the type of bath that she needs. Requirements were made at the last inspection for all staff to receive fire training at least six monthly. Sampled records indicate that most staff have had recent training but this is outstanding for some staff and must be done as a priority to ensure all staff respond appropriately in the event of fire. The lack of refresher fire training is a common theme across other SENSE homes. This is something the registered provider must address to ensure there are sufficient training places.Management arrangements require review to ensure the Manager has responsibility and accountability for all of the flats within the SENSE organisational structure.

CARE HOME ADULTS 18-65 Station Road, 11 Kings Norton Birmingham West Midlands B38 8SN Lead Inspector Kerry Coulter Unannounced Inspection 14th December 2005 10:45 Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 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.V273546.R01.S.doc Version 5.0 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.V273546.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Station Road, 11 Address Kings Norton Birmingham West Midlands B38 8SN 0121 459 8899 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) Sense West Mr Tom Harrison Care Home 9 Category(ies) of Learning disability (9), Physical disability (9), registration, with number Sensory impairment (9) of places Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The manager is supported by 3 deputy managers, each with responsibility for 2 flats Service users must be aged under 65 years The minimum number of suitably qualified and competent staff throughout the waking day is 7 per shift The shift pattern incorporates a handover period to enable an exchange of information between staff Care staff are generally assigned to specific flats Minimum night staffing levels are 4 suitably qualified and competent staff who will be awake throughout the night 12th July 2005 Date of last inspection 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 deaf blind people. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one Inspector. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from July 2005. At this inspection time was spent observing care practices, interactions and support from staff. Some of the service users do not have verbal communication and their ability to communicate to the inspector their views of the home was limited. A tour of the home was made. Service user care plans, risk assessments and a number of Health and Safety records were inspected. The premises and records of flats 1 and 6 were not sampled at this inspection. The Inspector had the opportunity to talk with several members of staff, the new Manager and the Assistant General Manager. During this visit the Inspector did not have opportunity to speak with relatives and other professionals. What the service does well: What has improved since the last inspection? The statement of purpose has been updated as required at the last inspection and now contains all the required information. Risk assessments have been further developed to include good detail to show clearly that they have been reviewed. Care plans continue to be reviewed and developed, but require further development. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 6 A recent audit of activities undertaken by the Manager indicates that the home has gone from 60 of planned activities taking place to 80 . Staff have recently attended a training session on menu planning and portion control. Staff who required it have received training in physical intervention. Epilepsy guidelines are now available for staff. These include descriptions of a seizure and the action staff must take in the event of a seizure occurring. Some internal decoration has taken place since the last inspection making the home a more pleasant place to live. Progress has been made on the recruitment of new staff. Staffing hours have been increased giving more flexibility to respond to service users needs. The appointment of a new manager has brought some much needed stability to the home. What they could do better: Care plans must be signed, dated and reviewed at least six monthly. The care plans must detail how any cultural needs will be met. Any guidelines in place must also be kept under review. Cultural and/or religious needs need to be taken into account when planning menus. The use of ‘as required’ medication requires improvement to ensure service users receive the medication they need. Further development of the homes healthcare monitoring systems were required regarding weight so that the home can evidence that the service users needs are properly monitored and kept under review. CSCI must be notified of all occurrences where physical intervention is used to ensure service users are protected from risk of abuse. One service user has not been provided with the type of bath that she needs. Requirements were made at the last inspection for all staff to receive fire training at least six monthly. Sampled records indicate that most staff have had recent training but this is outstanding for some staff and must be done as a priority to ensure all staff respond appropriately in the event of fire. The lack of refresher fire training is a common theme across other SENSE homes. This is something the registered provider must address to ensure there are sufficient training places. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 7 Management arrangements require review to ensure the Manager has responsibility and accountability for all of the flats within the SENSE organisational structure. 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. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 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.V273546.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The Statement of Purpose provides the information needed about services provided, and this is reinforced by assessment and admission procedures. EVIDENCE: The statement of purpose has been updated as required at the last inspection and now contains all the required information. The service user guide was not sampled. There have been no changes to the service users group since the last inspection. A referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals, an assessment would then be completed by the Manager. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 The care planning system in place does not always provide staff with the information they need to satisfactorily meet service users needs. The arrangements to support service users to make choices and decisions about their daily lives and routines was satisfactory. Substantial work has been undertaken to ensure the risk assessments are satisfactory, this process in near to completion. EVIDENCE: Four care plans were sampled. It was identified at the last inspection that often care plans and guidelines were not signed or dated. It was therefore not possible to evidence that the care plans had been kept under regular review. At this inspection most of the information in service user files was dated but not all. Some care plans had not been updated in the last six months but there was written evidence that most of these plans were in the process of being updated. However for one care plan no progress was evident since the last inspection. The section on daily living skills was blank and there was no adequate information as to how the cultural needs of the service user would be met. Both these issues were identified in the previous CSCI inspection report. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 11 Discussion with the Manager indicates that the home has been without a Practice Development Worker (PDW) for some time and this has increased the workload of Managers who have struggled to ensure all plans are up to date. Part of the role of the PDW is to update care plans. The Manager said that a new PDW has been recruited and is expected to commence work after Christmas. Evidence was available that other professionals are involved in the care of people who live at the home, for example the Speech and Language Therapist has completed assessments for eating and drinking. A care plan review meeting is also arranged annually, social workers, relatives or advocates are invited to attend as appropriate. Records evidenced that choice is offered to service users, this included times of going to bed and getting up, what to wear and choice of activities. Members of staff actively encourage each service user to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of objects of reference. Progress has been made since the last inspection with regard to risk assessments. The majority sampled had been reviewed in the last six months, work has also commenced to include the level of risk within the assessment. One risk assessment directing staff to wear long sleeve tops to prevent injury from scratching was not dated. The member of staff working in this flat was not wearing a long sleeve top. The Manager agreed to review the risk assessment to ensure the guidance to staff was appropriate. Service users individual records are stored securely. Staff are mindful of issues discussed in the presence of service users, and were not observed to breach confidentiality. The home uses accident books that are compliant with the Data Protection Act. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 17 Arrangements are in place so that service users experience a meaningful lifestyle to include participation in a wide range of activities. Service users enjoy a healthy and nutritious diet but the cultural needs of people needs to be reflected in the choice of meals offered. EVIDENCE: It was identified at the last inspection that too many planned activities were being cancelled for reasons such as no drivers and lack of staff. Discussion with staff and sampling of records indicates that the level of activities has now improved. A recent audit of activities undertaken by the Manager indicates that the home has gone from 60 of planned activities taking place to 80 . Each person who lives at the home has a timetable of daily activities. Service users are very much part of the local community. Sampled records indicate that activities participated in include walks, massage, shopping, pub visits, putting up Christmas decorations, library visits and the Deaf club. The menus were sampled in flat 4. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 13 Staff have recently attended a training session on menu planning and portion control and are now working on a four week rolling menu. There was little evidence that cultural or religious needs had been taken into account when planning the menu. Adequate stocks of food were available in the flats. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Further development of the homes healthcare monitoring systems were required regarding weight so that the home can evidence that the service users needs are properly monitored and kept under review. The medication system is generally satisfactory but the guidance on the use of ‘as required’ medication requires improvement to ensure service users receive the medication they need. EVIDENCE: Observation and records indicated that personal care is done in privacy and in a gender sensitive manner, in the service users’ bedrooms. The service users were well presented. Care plans indicated that service user’s health needs are generally being met. There are records of visits to other professionals when required. Since the last inspection epilepsy guidelines are now available for staff. These include descriptions of a seizure and the action staff must take in the event of a seizure occurring. Some health monitoring records were not up to date. For example the care plan recorded that one individual should be weighed monthly, however there had been a six month gap in their weight being monitored and in this time they had put on nearly two stone. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 15 Where individuals are unable to fully communicate their well being regular weight monitoring is important as weight gain or loss can be a sign that a person is unwell. The issue of irregular weight monitoring was identified as requiring improvement at the last inspection. Medication competence assessments are completed for all staff who administer medication. The majority of staff have had accredited training in medication. Medication was administered as directed, the Medication Administration Records (MAR) confirmed this. Photocopies of prescriptions are retained. In flat 3 the use of topical creams and ointments needed improvement. One tube had not been dated on opening. This is required and the ointment should then be discarded 28 days after opening. The location of the medication cupboard also requires review as it is adjacent to a doorway. People opening the door would be unaware that someone was behind it, this has the potential to cause an accident and also interruptions to medication administration. In flat 4 one service user is prescribed medication on an ‘as required’ basis for sleeping difficulties but there was no protocol in place to guide staff as to when it should be administered. Staff spoken with said its use had been discussed recently at a review meeting for the individual but they were unable to locate the records of this. The home has a system of having a medication file for each service user. It is recommended that the contents are reviewed as in some files it was difficult to locate current information due to the quantity of old letters and other documents located in the file. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff have received the right training to enable them to protect service users from the risk of abuse. Delays in an adult protection investigation and records on the use of physical intervention impacts on the homes ability to ensure that service users are being protected from abuse. EVIDENCE: Prior to the last inspection in July 2005 SENSE informed the CSCI and Social Care and Health of an adult protection incident concerning physical intervention. It was agreed that this would be investigated by SENSE who appointed a manager external to the region to investigate this matter. It is disappointing that the investigation has yet to be concluded, SENSE has been delayed in their investigations due to the investigating officer leaving their employment. Records on the use of physical intervention were sampled at the last inspection, these were found to require improvement. Since then there have been few incidents where physical intervention has been necessary. The record of one incident was sampled. It was unclear how long physical intervention had been used for, the report stated one hour and five minutes which seems an unacceptable length of time. It was queried with the Manager if staff had recorded the length of the whole incident rather than the actual physical intervention. Additionally, the CSCI had not been informed of this incident as required. The Manager agreed to investigate this matter. Since the last inspection staff who required it have received training in physical intervention. The majority of staff have attended adult protection training, staff still to attend have training places booked. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 17 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, 29, 30 The flats, although restricted in space are decorated and furnished to meet service users needs. Suitable adaptations have not been made to meet the bathing needs of one service user. EVIDENCE: Four of the six flats were examined at this inspection. The flats were observed to reflect the individual tastes of the people who live there. Although the flats accommodate only one or two people some were quite small in size, particularly in regard to size of kitchens and living/ dining rooms. The flats share a communal garden, this was observed to be a pleasant and well maintained area. Most flats have had some redecoration and new carpets fitted. Some flats have also benefited from new lounge furniture and net curtains. During the inspection engineers were working on upgrading the boiler to increase hot water supplies to the flats. Adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. This includes objects of reference attached to doors so individuals know where they are in the home. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 18 However, one service user has not been provided with the type of bath that she needs. An Occupational Therapy (OT) report dated April 2003 recorded that an adapted bath was needed. A care plan review with a Social Worker in October 2004 recorded that the service user would benefit from an adapted bath and that an OT assessment and funding should be pursued. There was no evidence that anything had been done towards achieving the outcome of providing a suitable bath. At the last inspection some areas of the home were observed to require further cleaning. Flats at this visit were observed to be clean. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 19 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): 33, 34, 36 Staffing arrangements are adequate to meet the needs of service users. EVIDENCE: The staff on duty were observed to support service users competently with patience and respect. Service users were supported by staff to undertake independent living skills at their own pace. The home had a number of staff vacancies at the last inspection, impacting on the level and type of activities offered to service users. Progress has been made on the recruitment of new staff. The Assistant General Manager said that four new staff had been recruited the previous week, leaving just two vacancies to fill. Staffing levels have also been increased in one of the flats due to an increase in the number of challenging behaviour incidents. Staff spoken with said that this increase in staffing had been very beneficial in assisting to meet service user needs. Staff recruitment files were sampled. These contained all the information as required by regulation, evidence that a Criminal Records Bureau (CRB) check had been obtained was available. The home also keeps a profile of agency staff to include their qualifications, experience and confirmation of CRB clearance. The details of a CRB were missing for two agency staff but the Manager was able to get written confirmation of satisfactory checks being undertaken before the end of the inspection. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 20 The supervision records for two staff and one bank staff were sampled. These indicate that staff are receiving appropriate supervision and support at regular intervals. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 21 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, 43 Satisfactory systems of quality assurance are in place. The health, safety and welfare of the service users had not been adequately promoted and protected. Management arrangements require review as the Manager does not have adequate responsibility and accountability for all of the flats. EVIDENCE: Since the last inspection a new Manager has commenced work in the home. Throughout the inspection the Manager was open and responsive to suggestions for improvements. Much of the new Managers experience is working with children and families, evidence will need to be supplied to demonstrate she meets the criteria for managing a care home for adults who have a learning disability and sensory impairment. An application must be made to the CSCI for registration. Systems are in place to assure quality. This includes monthly visits to the home by the General Manager who completes a report and forwards this to the CSCI. Audits are carried out periodically to include the staff files by personnel. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 22 Additionally, part of the role of the Practice Development Worker is to complete quality assurance audits this includes the level of activities on offer. Requirements were made at the last inspection for all staff to receive fire training at least six monthly. Sampled records indicate that most staff have had recent training but this is outstanding for some staff and must be done as a priority to ensure all staff respond appropriately in the event of fire. The lack of refresher fire training is a common theme across other SENSE homes. This is something the registered provider must address to ensure there are sufficient training places. Fire records indicated that an engineer has serviced the fire extinguishers, fire alarms and emergency lighting. Regular fire drills take place to make sure that all service users and staff are aware of the procedure to follow if there was a fire in the home. Since the last inspection the West Midlands Fire service have been consulted about the type of fire doors in the home and a new draft fire procedure. The fire risk assessment showed what action has been taken to ensure the risks of there being a fire are minimised. Staff test the fire alarms weekly and the emergency lighting monthly to make sure they are working. The inspection report of July 2005 raised concerns about injuries to staff from two service users no longer at the home. The Health and Safety (H&S) Department of Birmingham City Council issued the home with an improvement notice regarding the safety of staff. At this inspection evidence was provided that H&S are now satisfied by the actions implemented in the home. In two flats the fridge/freezer temperatures were not being satisfactorily monitored. This must be done daily to ensure food is stored at an appropriate temperature and to prevent risk of food poisoning. Water temperatures are checked on a regular basis to ensure the water is at a safe temperature for service users and does not present a risk of scalding. A valid certificate of employers liability insurance was seen. Lines of accountability within the home are unclear. The home is divided up into six flats. The proposed Registered Manager is responsible for two flats whilst two Unregistered Managers are responsible for two flats each. Discussions with the Manager and Assistant General Manager indicates that the Manager does not line manage the Unregistered Managers, generally does not work in all of the flats and does not have access to all records. It is therefore difficult to envisage how SENSE expects the Manager to have overall responsibility and accountability for all of the flats if registered. The management arrangements need review to address these issues. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X X Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X 1 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Station Road, 11 Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 2 2 DS0000041220.V273546.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must be signed, dated and reviewed at least six monthly. The care plans must detail how any cultural needs will be met. Any guidelines in place must also be kept under review. Outstanding from 30/9/05. Ensure staff follow control measures in risk assessments. The risk assessment must include all control measures in place, level of risk. Risk assessments must be reviewed at least six monthly or sooner if a critical incident occurs. Outstanding from 12/8/05. Menus must be reviewed to ensure service users are offered culturally appropriate meals. Outstanding from 30/8/05. Health monitoring DS0000041220.V273546.R01.S.doc Timescale for action 28/02/06 2. YA9 12(1) 13(4) 14/02/06 3. YA17 12(1) 15 30/01/06 4. YA19 12(1)(2) 30/01/06 Page 25 Station Road, 11 Version 5.0 5. YA20 13(2) 6. YA20 13(2) 7. YA20 13(2) 8. YA23 12(1) 13(6) 9. YA23 12(1) 13(6) & 37 10. YA29 23(2)(n) 11. YA35 18(1)(c) records must be kept up to date. Where individuals are assessed as needing to be weighed monthly this must be done, or a record made that the individula has declined to be weighed. Outstanding from 30/8/05. Topical creams and ointments must be dated on opening and discarded after 28 days. Outstanding from 30/8/05. Medication prescribed on an ‘as required’ basis: Written protocol must be in place to guide staff as to when it should be administered. The location of the medication cupboard in flat 3 requires review to reduce risk of accidents and distractions when administering medication. The Manager must investigate and clarify with the CSCI the duration of physical intervention used on 9/12/05. CSCI must be notified of all occurrences where physical intervention is used. Suitable bathing adaptations must be made for one service user, in line with Occupational Therapists recommendations. Staff must receive training in all mandatory 30/01/06 30/01/06 28/02/06 30/01/06 15/12/05 30/01/06 30/01/06 Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 26 12. 13. YA37 YA42 9 & 10 13(4) 16(2j) 23(2d) 14. YA42 13(4) 23 15. YA43 12(1) areas. A training plan must be forwarded to CSCI. Requirement from 19/9/05, not assessed at this inspection. An application must be made to the CSCI to register a manager. Fridge and freezer temperatures must be monitored on a daily basis with a record maintained to ensure food is stored at a safe temperature. Outstanding from 19/7/05. Ensure all staff receive fire training at least six monthly. Outstanding from 12/8/05. Management arrangements require review to ensure the Manager has responsibility and accountability for all of the flats within the SENSE organisational structure. 30/01/06 15/12/05 04/01/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that the contents of the health files are reviewed as in some files it was difficult to locate current information due to the quantity of old letters and other documents located in the file. Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 27 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 Station Road, 11 DS0000041220.V273546.R01.S.doc Version 5.0 Page 28 - 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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