Inspection on 04/09/07 for 11 Station Road

This inspection was carried out on 4th September 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Station Road 12/02/07

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 Ann Farrell Key Unannounced Inspection 4th September 2007 08:30 Station Road, 11 DS0000041220.V343327.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.V343327.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.V343327.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.V343327.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 12th February 2007 Brief Description of the Service: 11 Station Road is a two-storey purpose built care home that is 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 three flats with two bedrooms, and three flats with one bedroom. All flats are self-contained with a kitchen, lounge, bedroom plus an en-suite bathroom. There is also a communal lounge and kitchenette plus a separate laundry room for laundering of resident’s personal items. A large communal bathroom on the ground floor, which would be suitable for someone with additional physical needs. There is a small staff office on the ground floor and a further office on the first floor A large, landscaped garden to the rear of the building, which is well maintained with features to aid access for deaf blind people. In addition table and seating is available for use when the weather permits. Off road parking is available to the front of the building. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 provision that needs further development The inspection was conducted over one day commencing at 8.30am and the home/provider did not know we were coming. This was the first statutory key inspection for 2007/2008 and a senior manager was present for the duration of the inspection. Information for the report was gathered from a number of sources: a questionnaire was completed before the inspection; on the day of inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home plus conversation with managerial and care staff and some residents. The residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used as part of the inspection process and staff used various communication methods to interpret for the inspector. Two residents 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 peoples care helps us understand the experiences of people who use the service. Written and verbal comments were also received from relatives and health professionals. All feedback was positive about the care provided and the staff. What the service does well: This service has brought together a group of residents who had previous group home placements and all exhibited extreme challenging behaviours. All are accommodated in individual self-contained flats and the incidence of challenging behaviours over time have diminished dramatically indicating a successful formula for meeting the very complex needs of this group. Feedback from family was positive with comments such as “Residents are treated well by staff and I am grateful to them”. “Regular staff have a good understanding and are able to sign, which in my opinion is important”. “The care home is exceptional, the care is excellent”. ”Regular staff have residents interest very much in their sight and residents horizons have been broadened”. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 6 The accommodation is of a high standard with spacious flats and good selfcontained facilities. All include lounge/dining area, bedroom, kitchen and ensuite area with bath/shower, which have been personalised to each resident’s preferences. The well-laid garden area compliments the indoor facilities. A committed and experienced staff group understands the complex and high dependency needs of residents. Allocation of staff is individual to each person. All residents had individual care plans that were comprehensive and person centred providing the information required for staff to support residents in the most appropriate manner. Records included health action plans, which are a personal plan about what a person needs to stay healthy and what support they need to go to healthcare services. All residents had a range of risk assessments undertaken in order that risks could be identified and action taken to reduce them, enabling residents to live a fulfilling life. Residents were well dressed, which was appropriate to their age, individual style and weather. There were a range of activities both in house and outside the home that residents undertook with the support of staff, so providing appropriate stimulation and enhancing their lifestyle on a day to day basis. Vehicles are provided by the home to enable residents to access the community. Resident’s health care needs were well met and feedback from health professionals indicated that staff did a good job. Residents were involved in the planning of the meals each week, so ensuring their choices are taken into consideration. Resident’s finances were checked on a regular basis, so ensuring good systems were in place for managing resident’s personal money. What has improved since the last inspection? There has been a range of staff training so ensuring staff have the appropriate skills and knowledge to care for residents. The flats have been re-decorated and furnished, so enhancing the environment for residents. They have had a new vehicle, so residents are able to access community facilities and enhancing their day-to-day activities. Staff had arranged a visit to the pear tree, which is a multisensory environment that has opportunities for different activities. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 7 Many of the residents were able to have a holiday last year, which they enjoyed, so providing a more fulfilled life. 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. Station Road, 11 DS0000041220.V343327.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.V343327.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): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available for prospective residents and their representative in a format that was accessible, enabling them to make an informed decision about moving into the home. A comprehensive assessment process was undertaken for any new residents to determine if the home was suitable and staff could meet their needs. This provides confidence to prospective residents and their representatives that their needs will be met appropriately. EVIDENCE: There were seven residents residing in the home and all had been there for a considerable period of time. There was information available about the services and facilities on entering the home. In addition, the last report from the Commission was also available. They also have a handbook that can be produced in the persons preferred format e.g. audiotape, large print etc. plus a virtual tour of the home on DVD was available, so that anyone visiting can make an informed decision about moving into the home. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 10 One resident had recently been admitted to the home and the assessment process was found to be comprehensive with a pre-admission assessment, the person visited the home on a number of occasions, staff visited their original placement and there was discussion with relevant professionals to determine if the persons needs could be met and the support provided before moving into Station Road. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 11 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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available to staff indicating the support that residents needed. Staff provided the appropriate support to enable residents to make choices and undertaken risks in their day-to-day lives enabling them to achieve their goals and aspirations. EVIDENCE: All the residents in the home have complex needs as they are deaf and have a sensory impairment. Communication methods vary depending on the needs of the resident and can include body language, signing, the use of photographs, pictures and objects of reference. Residents had communication boards in their individual flats identifying staff and events in their lives. Interaction between staff and residents was observed to be good and residents were seen to be relaxed, smiling and using gestures to indicate they were happy when communicating. A member of staff undertook signing to enable the inspector to talk to one of the residents and the feedback indicated they were happy living in the home. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 12 All residents had individual care plans, which were stored in their own flats. On inspection of a sample of care plans they were found to be comprehensive with background and important information about residents past history, family, likes and dislikes, communication, preferred activities, their needs and strengths, the preferred gender of staff to provide support etc. There were detailed plans about the morning, evening and night time routine and it was clear that residents were able to make choices about aspects of their daily lives. In addition, there were some individual support strategies and guidelines for areas such as eating and drinking, behaviour etc. and in some cases devised by professionals working in partnership with staff in the home. There was also a range of risk assessments, which stated how all risks to individuals were to be minimised without compromising their development and independence. Each risk assessment was cross-referenced to the element(s) of the care plan to which it related, and vice versa, so that the reader is directed from one to the other. This document provides staff with the information they require to meet resident’s needs. The information provided indicated that there are plans for a support worker development day in the future where information will be shared about different persona centred planning tools. This will enable a more creative approach when reviewing resident’s goals and aspirations. On inspection it was found that the care plan was detailed, had been reviewed and updated. The practice development worker who is based in the home was responsible for ensuring all care plans were up dated. On discussion with the practice development worker they stated they were also responsible for undertaking practice observations to determine if residents care plans were being implemented and these were yet to be completed. Daily records were recorded by staff for each shift indicating the activities or care provided during the day plus diet and fluids taken, so enabling staff to monitor residents progress and well being. The daily records were of a satisfactory standard providing information about the support given to residents, the activities undertaken and the response of the resident, so that staff could determine if it was suitable or if changes were required. Core team meeting were undertaken by staff on a monthly basis where a resident’s condition, progress etc. was discussed and any concerns highlighted. It was noted on one residents file that they had missed activities outside the home due to transport problems. On discussion with the manager present it was stated that a review of the transport needs was being undertaken with a view to securing a more appropriate vehicle to suit resident’s needs. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 13 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 excellent. This judgement has been made using available evidence including a visit to this service. Individual lifestyles are known by staff and acted upon. Staff support residents with a range of activities, so providing stimulation and a meaningful lifestyle. Staff are hoping to develop this further to enhance the skills of residents. Meal provision is individual and meets the needs of residents, so they receive a nutritious diet. EVIDENCE: Resident’s files had a list of activities they enjoyed enabling staff to arrange a variety of activities to meet their needs and preferences. There was an individual programme of activities for all residents depending on their preferences. Activities included going out for walks, to the pub, for a meal, to church, to the library, swimming, cinema, rock climbing, music, massage, art, writing letters to family etc. It was also stated that some residents work at the organisations garden room, where they are involved in producing garden furniture etc. when they want. Residents have also started visiting the pear Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 14 tree, which is a multi sensory environment that has different opportunities for activities. The manager also stated that they were looking into the option of some residents attending college courses in order to develop their skills. All residents have the opportunity of taking an annual holiday and this is planned with staff taking their wishes and preferences into consideration. The home has three vehicles to transport residents to activities and a review is currently being undertaken due to residents changing needs. Some residents also use public transport to assess community-based activities. Family contacts are promoted, so enabling residents to maintain contact with relatives and keep them updated with any events and changes. Some contacts are very regular others less regular due to distance, circumstance etc. One resident does not have any active family involvement and it was stated that staff were looking for advocates, who could provide the resident with support. Feedback from relatives was very positive e.g. “ The care home is exceptional, the care is excellent. The regular staff have residents interests very much in their sight and residents horizons have been broadened though activities”. “They phone weekly and always have time for my worries”. SENSE also has a family liaison officer who’s role it is to facilitate working with families. They have held a ‘family weekend’ at a local hotel, in the past and this provides an opportunity for relatives to keep up to date with SENSE plans, meet with staff and other relatives. Residents were involved in making choices about the meals they want. They are involved in the shopping and preparation of the meals with support by the staff in their own flat, so maintaining their independence as much as possible. Records of food intake were maintained and residents were weighed on a regular basis to monitor that they were taking a nutritious diet. Some residents were seeing the dietician on a regular basis and they were doing very well with their diet. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs were well met and they receive support from staff for personal care where required that meets their needs. The arrangements for medication require further development to ensure robust procedures and residents receive the mediation prescribed by health professionals. EVIDENCE: All residents live in their own flats and staff provide support on an individual basis, so providing the level of care they require. All flats have en-suite facilities with appropriate equipment to support residents to ensure privacy and a degree of independence in resident’s lives. Information about the support residents required in order to maintain personal hygiene was included in their care plan. Care plans also included manual handling assessments and information on gender specific support. Residents were dressed appropriately for their age, culture, gender and weather. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 16 All residents were registered with a local G.P. service. Records showed that residents had regular check ups with the dentist, chiropodist and optician and other health professionals as required. Records seen also showed that annual health checks had been carried out as required. Residents were weighed on a regular basis to monitor nutritional status. Staff had received some training in healthy eating and they had been positively applied with good results for some residents. Each resident has a health action plan; this is a document that outlines the care a resident with learning disabilities requires to stay healthy. The manager stated that if a resident were admitted to hospital they would support them throughout their stay by a member of staff. All residents have high dependency needs with severe learning disability, varying levels of hearing/sight and a degree of challenging behaviour in the past. Communication is by means of BSL (British Sign Language), Hand over hand or by objects of reference and there were communication symbols available in resident’s flats. Comments received indicated that regular staff have the skills to communicate with residents,” Regular staff sign and do so, which is important”. The incidence of challenging behaviour has reduced from the time of resident’s admission and if there are any incidents records are maintained and staff have been trained in how to manage it. Medication is stored in each flat in cupboards with locks and keys were available. However, it was found in some instances that the cupboards were not locked or the key was left on the dining table accessible to residents. This practice should be reviewed, as there may be a risk to residents. On inspection of the medication for two residents it was found that one audit was not correct, some creams and eye drops had not been dated when opened and eye drops did not indicate which eye they should be used for. These measures are required to reduce the risk of bacterial contamination. There have also been incidents where medication was not administered or was missing that have been reported to the Commission by the manager. The manager who was present stated that they had planned a meeting with the pharmacist with a view to further staff training in order to address the issues. A nebuliser was in use for some medication and staff had ordered a filter, which need to be changed on a regular basis to ensure it remains in good working order. They had also obtained a smaller machine that could be used when travelling. Station Road, 11 DS0000041220.V343327.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place to deal with any complaints, concerns or allegations that are raised with clear policies and procedures, so ensuring residents are protected. EVIDENCE: There was a written compliant procedure on display on entering the home. The majority of residents have family support as a means of identifying concerns or complaints. Feedback from relatives indicated that some of them were not aware of the complaints procedure and this will need to be addressed to ensure they are aware of the procedure in the event of any concerns. The Commission had not received any complaints about the home. The information provided by the home indicated there had been four complaints, which had been investigated within 28 days and only one had been upheld. Also there had been one referral under the safeguarding procedures. The information about the complaints and referral under the safeguarding procedures was not available, as records had been taken by the manager for a staff disciplinary hearing was to take place in respect of one of the complaints raised. Two residents financial records were sampled and the money was held in individual wallets. Money cross-referenced with the amount on their financial records and receipts were kept for all transactions, so ensuring a good procedure for the management of resident’s money. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 18 Staff record and notify the Commission of all instances of challenging behaviour and instances of physical intervention used by staff, so that this can be monitored and any triggers identified. Recently the Commission were notified of three incidents that were correctly referred under Vulnerable Adults procedures by the home and staff were suspended, as part of the required procedure. At the tiem of inspection there was no record of the outcome of the referrals and the inspector was informed that a disciplinary hearing was to take place in respect of one of the cases. The manager will need to inform the Commission about the outcome of all incidents when investigations and hearings are complete. Staff receive training in respect of the safeguarding procedures and on discussion with some staff they demonstrated an adequate knowledge of what to do in the event of an allegation. Station Road, 11 DS0000041220.V343327.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): 24,25,27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Facilities are of a high standard with self-contained accommodation in 6 flats, which have facilities and equipment necessary to maximise resident’s independence and meet their needs. EVIDENCE: The complex was a modern two-storey building designed specifically to meet the needs of residents, which was opened in 2002. It is owned by Accord Housing Association and is well maintained. Access to the building is by a main door or keypad system. Within the complex were three single bedroom flats and three double bedroom flats. Each flat was self-contained providing a spacious lounge/dining room; separate kitchen, a bedroom and en-suite bathroom facilities all with baths/showers. In addition, there was a large communal dining/recreation room and kitchen and also separate toilet with communal shower area. The home was adapted to meet the needs of people with a sensory impairment and Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 20 a call bell was available in each flat to summon assistance if required. The building was well furnished, light, spacious and decorated to a high standard. All bedrooms were personalised to reflect resident’s different tastes and interests and there were plans to make the communal lounge more person centred. The information provided also stated they hope to develop the garden to provide a more sensory experience. There was an excellent and well-planned communal garden area, which was private and safe. There was level access from the building to the garden and in some cases there was direct access from flats on the ground floor. There was a range of seating and other facilities enabling use when the weather permits. Appropriate bathing facilities and specialised equipment had been provided for a resident with declining mobility. Other aids such as handrails were also available. All areas of the home were clean and hygienic and a member of domestic staff was available for cleaning communal areas. There is a separate laundry area that is used for laundering of residents clothing etc. and it was well equipped. Station Road, 11 DS0000041220.V343327.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good staffing levels were maintained and there was a committed staff group who had undergone a range of training, so ensuring residents needs were being met appropriately. There was a robust staff recruitment procedure in place to ensure residents were protected when new staff were recruited. EVIDENCE: The staffing arrangements consist of three managers. Each is responsible for two flats and work under the direction of the registered manager. Care staff are allocated to a specific resident group, which results in 1:1 staffing for residents in single bedroom flats. In double bedroom flats there may be one or two staff depending on the needs of the residents. During the waking day there are at least seven staff on duty, which is a condition of the homes registration. There were at least four staff on duty overnight and the staffing arrangements at the time of inspection appeared satisfactory to meet resident’s needs. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 22 There is a fairly static staff group with only five staff having left the home in the last year and no use of agency staff over the past three months. Where there were any shortfalls they are covered by regular staff, so ensuring continuity of care to residents. Staff were pleasant and helpful. They were observed to treat residents with respect, observe their privacy and were able to communicate effectively with them. Staff were allocated to specific residents and therefore have an in-depth knowledge of their needs and experience in dealing with any potential difficult situations. A sample of staff files were inspected to determine the recruitment process and they were found to be of a good standard with an application form, appropriate checks completed and record of interview, so ensuring residents are protected. Induction training for new staff was organised centrally by SENSE and includes areas such as protection, first aid, equality, values, diversity, working with deaf/blind people, communication manual handling, medication, challenging behaviour etc. Staff also complete modules over the six-month period that have a question and answer section. This ensures staff receive the training required to meet residents needs initially. Staff also undertake an induction into the home and receive a starter pack and this was recorded for a new member of staff. The record of staff training indicated that the majority of staff had completed basic core training in respect of first aid, health and safety, food hygiene, protection, manual handling, values etc. On inspection of staff files this was not consistently confirmed by evidence of the training. Areas that were not up to date included fire training and fire drills. This will need to be addressed to ensure staff are fully aware of the procedure in the event of a fire and residents are protected. The information provided indicated that nine staff had completed NVQ level 2 training in care, so providing them with the knowledge and skills to care for residents. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements are currently being reviewed. In the meantime there are suitable management arrangements in place to ensure the systems are implemented and residents benefit from a well run home. Arrangements are in place to ensure that the health, safety and welfare of residents is promoted and protected. EVIDENCE: The management arrangements in the home currently consists of a registered manager who overseas the whole complex and three unregistered managers so each have responsibility for two flats. At the time of inspection the registered manager was on leave of absence and a general manager was taking overall responsibility. At the last inspection it was stated that the management structure was being reviewed and a requirement was made that Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 24 the Commission should be informed of the arrangements when finalised and this remains outstanding. The home has an extensive quality assurance system with self-assessment and audits of all areas. They have recently started to obtain feedback from visitors to the home such as relatives, NVQ assessor etc. There are core team meetings where areas that require action are identified. Also visits are undertaken by a manager on a monthly basis to assess the conduct of the home, which are unannounced and a copy of the reports are sent to the Commission, as required under the regulations. The information provided by the manager in relation to servicing and maintenance of equipment indicted that it was all up to date. A sample of records were inspected to include fire system, emergency lighting, fire extinguishers, electrical appliances gas safety certificate etc. At the time of inspection the gas safety certificate and check on fire extinguishers was dated March 2006 and there was no evidence that the wheelchairs and bath seat had been serviced. These areas will need to be followed up to ensure all equipment in the home is safe for use. Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 25 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 4 X X X 2 Station Road, 11 DS0000041220.V343327.R01.S.doc Version 5.2 Page 26 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 Standard YA20 Regulation 13(2) Requirement Topical creams and ointments must be dated on opening and discarded after 28 days to reduce the risk of bacterial contamination. Outstanding from 30/8/05. Systems must be in place to ensure the accurate administration and recording of all medication to ensure residents receive the medication prescribed. Review the arrangements for the medication keys to ensure residents safety at all times. 3. YA22 17(1) The record of complaints must be retained in the home at all times, so that they can be viewed at inspection to determine that residents are protected. All staff must undertaken fire training and fire drills at least twice a year to ensure they are fully aware DS0000041220.V343327.R01.S.doc Timescale for action 25/09/07 2. YA20 13(2) 25/09/07 25/09/07 4. YA35 23(4) 30/11/07 Station Road, 11 Version 5.2 Page 27 5. YA37 12(1) 6 YA43 13(4) of the action to be taken in the event of a fire and residents are protected. Outstanding from 12/8/05 The Commission should be informed of the management arrangements in the home so that they can be assured of suitable arrangements. Evidence should be provided to confirm servicing of • Gas equipment • Fire extinguishers • Wheelchairs • Bath seat 30/11/07 30/10/07 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 3 Refer to Standard YA23 YA35 YA35 Good Practice Recommendations The manager should inform the Commission regarding the outcome of the adult protection referrals, so they can be assured that appropriate action has been taken. Evidence of the training staff have completed should be held in the home to demonstrate the training completed and the range of abilities. 50 of all staff should be trained to NVQ level 2 to ensure staff have the skills and knowledge to care for residents. Station Road, 11 DS0000041220.V343327.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. 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