Inspection on 05/02/07 for 218 Stourbridge Road

This inspection was carried out on 5th February 2007.

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

The inspector found 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

218 Stourbridge Road 19/12/05

218 Stourbridge Road 04/08/05

218 Stourbridge Road 17/03/05

218 Stourbridge Road 14/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Stourbridge Road, 218 218 Stourbridge Road Bromsgrove Worcs B61 0BJ Lead Inspector D Lewis Unannounced Inspection 5th February 2007 10:30 Stourbridge Road, 218 DS0000061839.V312554.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 Stourbridge Road, 218 DS0000061839.V312554.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. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stourbridge Road, 218 Address 218 Stourbridge Road Bromsgrove Worcs B61 0BJ 01527 579611 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) Worcestershire Mental Health Partnership NHS Trust Mr Wayne Stanley Casey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: 218 Stourbridge Road is a traditional detached house approximately 1½ miles from Bromsgrove town centre, providing a home for up to five people with mental health needs. There is easy access to public transport and the town centre, including the Bromsgrove Mental Health Resource Centre. The home includes ground floor bedroom and bathroom facilities. Service users have their own furnished bedrooms with two lounges (one where smoking is allowed), a dining room and kitchen shared by the household. The home aims to provide a homely environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. The manager, Wayne Casey, began working in the home at the end of January 2005, and was registered in June 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual for the Trust is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. Written information about the home is available in a service users’ guide and a statement of purpose. Current charges at the home are £785 per week. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection of 2006-7. It was a Key Inspection. This means that the inspector checked all of the standards which have most impact on service users, taking into account any information received about the home and including a visit to the home. The inspector was in the home from 10.30 a.m. until early evening. The inspector met and talked with several service users; with staff on duty; and with the registered manager, Wayne Casey. All were welcoming and gave useful information. Two service users spent a length of time with the inspector and were very helpful. The inspector sent questionnaires about the home to service users and to their relatives. One service user and 4 relatives returned the questionnaire. Their views are taken into account in this report. The inspector was assisted by an Expert by Experience (in this report known as “the Expert”). This is someone with personal experience of using mental health services, who has been trained to accompany CSCI (Commission for Social Care Inspection) inspectors during inspections. Their aim is to observe what happens in the home and talk to service users, to acquire a service users’ point of view of the home. The Expert talked with service users and provided a report of her findings. Parts of her report have been included in this report. What the service does well: Written information about what the home does is available to service users. The care people need is written down and kept up to date, and service users can be involved with this if they want. Service users say they can make their own decisions and can live independent lives. Staff help them to do so as safely as possible. Service users can do training, education or work if they want. They do ordinary activities like going for a meal, to the cinema or going bowling. Relatives are welcome in the home. Daily life is not restrictive. The home provides a choice of meals. Service users like the food. Staff help service users to keep healthy and to feel secure. They look after medication safely. Staff are open to listening to any concerns. Service users and relatives feel comfortable with raising concerns. During the past year CSCI has not received any complaints about the home. The home is mostly clean, homely and well maintained. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 6 There are enough staff in the home to give the care people need. Staff are suitably qualified, and service users like them. Service users and staff like the registered manager. The home has started to find out what service users and relatives think of the home and to make changes as a result. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient written information available about the home. People’s needs are assessed before they move into the home. Service users have contracts. EVIDENCE: The home has a stable group of service users, with no new admissions since the beginning of 2005. A standard copy of the contract will be attached to the service users’ guide when next provided, as will a summary of service users’ views (most recently collected approximately 2 months ago). Service users admitted in 2005 had full assessments of their needs before admission and the registered manager is aware of the need for this to be done before any new service user is admitted. A sample of service user records was checked and ongoing assessments of their needs were seen, which were being reviewed every 6 months and translated into care plans. The Trust has now provided contracts to existing service users. One service user confirmed this. Another stated they could not recall this, but would in any case have asked for it to be kept in the office, as they were not interested in it. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 9 Stourbridge Road, 218 DS0000061839.V312554.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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know about their plans of care, which are kept up to date by staff. Service users are able to make their own decisions, and are supported in taking risks as part of an ordinary lifestyle. EVIDENCE: A sample of service user records was checked. Ongoing assessments of their needs were seen, which were being reviewed every 6 months and translated into care plans. The care plans were being evaluated regularly. The registered manager was setting up a system of regular 6-monthly review meetings, with all relevant people being invited to attend (e.g. service user, consultant psychiatrist, day centre staff, family (if the service user wants this). The home was already reviewing plans regularly with relevant people e.g. day centre activities with day centre staff), but was intending to collate all information for a full 6 monthly review. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 11 The registered manager had instigated a system of monthly meetings between the service user and their key worker, specifically to discuss their aims and aspirations. One service user’s recorded aims were to have a foreign holiday, and to go sailing. The home was working to help this person achieve their aims. Service users were involved to varying degrees with their service user plans, depending on their level of interest and motivation. One person said “I have a say with my care plans”. A service user told the Expert about their personal goals, stating “the goals were his goals.” Service users mainly were able to make their own decisions. One person said “I can do pretty much what I want”. There was no evidence of restrictions on service users’ choice and freedom, apart from one person who was always accompanied by staff when out of the home, due to their specific mental health needs. Staff explained this person would never want to leave the home without staff. The inspector understood this and advised that the reasons for staff always accompanying this person should be recorded and reviewed. Service users told the Expert about attending regular House meetings to talk about things like activities and menu planning. The Expert suggested the home could further develop service users’ ability to contribute to bigger decisions about the running of the home. Risks to service users were being assessed, recorded and reviewed. Most seen dated from, or had been reviewed in, 2006. There were a few where it was not clear that they had been reviewed since 2005, but the registered manager informed the inspector that new systems would ensure all risk assessments will be regularly checked. Service users were able to undertake ordinary activities such as swimming, using the kitchen and going out alone. Staff assessed the risks and took action to reduce them. The home had a procedure to follow in the case of missing persons, which was readily available to staff. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users’ involvement with work, training or education varied widely according to individual needs. One person had limited activities outside the home due to significant mental health needs. Other service user had done college courses such as French and cookery. Service users took part in ordinary community activities, including some at weekends and in evenings. Service users mentioned going out for a meal, to the cinema or going bowling. The home was keeping records of activities, including those offered and declined, for each service user. The records showed that efforts were regularly made to enable service users to have access to enjoyable activities, including any person whose mental ill health led to reduced motivation. One person had told the Expert that their life was “a bit Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 13 boring”. This person’s notes referred to them being reluctant to try different things, and there were records of activities being offered which were not always taken up. The registered manager had sought relatives’ views on the service provided by the home, most recently before Christmas 2006. He had taken action on what had been reported, e.g. 2 relatives did not know of the home’s complaints procedure, so he had re-issued it to all relatives. He had been proactive in promoting further family involvement, by inviting relatives to service users’ 6monthly reviews and by starting to hold family days (e.g. a Mothers’ Day gathering) at the home. In addition, the home had begun to hold relatives’ meetings every 3 months, giving a valuable opportunity for relatives to keep involved and in touch with the home. 4 relatives responded to the CSCI survey and all indicated they felt welcome in the home at any time and could visit their relative in private. One relative commented “We are very happy with the quality of care provided at 218 Stourbridge Rd. …….. and we feel very welcome.” Daily routines were unrestrictive. Service users said they were called by their preferred name, they held keys for their rooms, but not for the home as there were always staff on duty. They opened their own post, and staff knocked and waited before entering their bedrooms. The inspector observed staff interacting freely with service users in a friendly and sociable manner. Service users said they had some responsibility for housekeeping tasks, on a rota basis. The Expert noted that one service user found that house rules “made the home a bit abnormal, not a home”, but did not describe rules other than food being thrown out as it was out of date. Another service user told the Expert that house rules were “common sense”. The inspector joined service users for lunch, saw the menu and discussed the food with service users and staff. Service users liked the food. The menu was planned in a weekly house meeting. The inspector and the Expert saw options being offered for lunch, and one service user said “I can eat what I like”. Service users were able to be involved with food preparation and one service user cooked the whole meal on occasion. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and health care needs were being suitably supported by staff. Medication was being managed safely, although staff need to be careful about keeping clear records. EVIDENCE: The inspector sampled service user plans and found suitable plans for supporting service users with their personal care. Service users confirmed that staff treated them well and were sensitive about matters such as privacy. Service users seen at the inspection did not have specific health care needs or did not wish to discuss them. The inspector saw service user plans for other service users’ health needs, which were suitable and up to date. One person had been supported by staff to take control of their own treatment of a chronic health condition. The inspector also discussed health issues with staff. Treatment of one person’s deteriorating mental health had been appropriate. Another person’s mobility had been greatly improved through effort on their part with much staff encouragement and support, making this person healthier Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 15 and more independent. In another instance, a member of the public had commented on staff’s approach to a particular health need and this had led the team to revise their approach in a responsive way. Service user plans included separate records of healthcare contacts with their GP, optician, dentist, chiropodist and psychiatric services, as well as routine blood testing dates. They also included weight charts and, where needed, records of food and liquid intake. All service users had annual health checks. A health professional had responded to a CSCI questionnaire and had reported that staff understood service users’ care needs and worked in partnership with health staff. The inspector saw medication storage, administration and records including records of medication received in the home and administered to service users, records of current medication, returned medication and of service users’ consent to take medication. All were satisfactory, although the inspector noted 2 entries which had been scribbled out, a code in use that was not defined, and a discrepancy between the dose being given and the dose specified on the pharmacy label for some lactulose. The registered manager was aware that such practices were not suitable and undertook to speak to staff about accurate record keeping, and to liaise with the pharmacist about getting the labels changed to match the prescribed dose. Records of incoming medication were in place but were limited in detail. All staff had had updated training in medication during 2006. Keys were kept securely. No service users had “as required” medications. Some service users looked after their own medication, having been assessed as safe and capable to do so. They had support from staff with this, and safe storage areas. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were able to raise concerns with staff. Staff were trained in protection of vulnerable adults. EVIDENCE: The home had a suitable policy on responding to concerns or complaints, which included CSCI (Commission for Social Care Inspection) contact details and gave an assurance that any concern would be dealt with within 28 days. The home kept a record of complaints or concerns, and of the action taken in response to them. Service users said they could talk to staff about concerns. No relatives had needed to make complaints, 2 said they did not know of the procedure but the registered manager had provided everyone with further copies and information since this had come to light. CSCI (Commission for Social Care Inspection) had not received any complaints about the home since the last inspection. The home had a suitable policy on Protection of Vulnerable Adults. All staff had done training in this area in 2005, except for two who were booked on training in March 2007. There had been no concerns about abuse in the home. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well decorated and maintained, but the Trust has been slow to carry out required maintenance work in the home, leaving some areas shabby for years. In addition it is not clear whether the Trust has carried out measures required to ensure electrical safety. Service users like the premises. There are sufficient shared areas in the home, and the manager has begun to improve the garden area. The home is clean and free from odours. EVIDENCE: The inspector toured the home and saw one service user’s bedroom. The home was clean, homely, accessible for people with restricted mobility (there were 2 downstairs bedrooms and a large downstairs bathroom) and generally well maintained. The exception was one upstairs bathroom which had been in need Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 18 of renovation since at least 2005, when it was identified in an inspection report as being shabby, with broken tiles and a broken shower. The registered manager said this was finally due to be refurbished, before the end of March 2007. It was disappointing that it had taken the Trust so long to bring the accommodation to a reasonable standard, but good news that it was finally being done. The inspector noticed large boxes of paper towels stored in a downstairs bathroom, giving a less than homely feeling. This was not discussed during the inspection, but hopefully an alternative storage area can be found. Bedrooms and bathrooms were lockable and were suitably furnished, apart from the bathroom mentioned above. The garden was open-plan, on a site shared with health care facilities, giving an institutional feeling. The registered manager had arranged for voluntary gardeners to begin work on enclosing a level section of the garden to make a secluded area for barbecues, relaxing etc. during summer months, and this work had begun. Within the home there were 2 lounges, one for smoking or for private visits. The Expert noted that privacy was more difficult when talking with service users in other areas, due to people coming and going. The laundry was suitably sited and equipped. Sluice facilities were not needed in the home. There was a policy on infection control. The home was clean and free from odours on the day of the inspection. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has enough staff, and they are suitably trained and qualified. Usually recruitment follows required procedures, but the registered manager must ensure this is always the case, to reduce the risk of employing unsuitable staff. EVIDENCE: The staff rota showed sufficient staff on duty, although there were fewer during the evenings, meaning evening activities (where service users needed or wanted staff support) were limited to pre-planned activities, when extra staff could be, and were, added onto the rota. The registered manager said he hoped to change the shifts worked in the near future, to enable service users to have easier access to activities and staff input during evenings. Most staff held NVQ (National Vocational Qualification) level 3 in Care or Promoting Independence. The home had a training plan showing which staff had done training and which training was planned or booked for the year. Most Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 20 basic training was in place. All staff had first aid, medication and food hygiene training. Most had been trained in infection control, manual handling, equality and diversity, protection of vulnerable adults, MAPA (management of actual or potential aggression); those who had not been trained, or whose training was out of date, were booked on, or prioritised for, training in 2007. In addition some staff had done training in other relevant topics such as hearing voices, schizophrenia and self-harm. New staff underwent an induction according to Skills for Care standards. Staff relationships with service users were seen to be friendly and relaxed. Service users said they got on well with staff and could talk to them. One relative commented “The team of staff under the leadership of Wayne Casey is dedicated and friendly….” The inspector discussed varying staff approaches to service users with the registered manager, and ways in which staff can ensure service users feel respected at all times. The Expert noted that sometimes staff related to service users in a slightly parental way and that on occasions staff had talked to her or the inspector about a service user, in front of the service user. The Expert also noted staff were welcoming and made efforts to engage a withdrawn service user. Appropriate recruitment procedures were generally carried out with new staff, including written applications, interviews and obtaining CRB (Criminal Record Bureau) disclosures before they began work in the home. The inspector noted one case where a staff member had begun work in the home before their CRB (Criminal Record Bureau) disclosure had arrived. The registered manager explained the staff member had been fully supervised. However this is not permitted unless there is an urgent need for staff to start work (and service users will suffer if they do not) and a POVAfirst check has been obtained. This was not in evidence. Service users sometimes had some involvement with choosing staff, but this could be increased with training. The Expert noted that one service user remembered helping to choose a staff member, while another said that was “up to the manager”. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced, qualified and liked by staff and service users. The home has partly commenced its quality assurance process, and remaining work is soon to be complete. The home follows safe working practices. However the registered provider (the Trust) has been slow to carry out essential maintenance in the home, even when it may affect service users’ health and safety. EVIDENCE: The registered manager had been in post since 2005 and had been a registered manager in another home before then. He had completed his Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 22 Registered Manager’s Award in February 2006, and had found the training interesting and beneficial to his practice as a manager. Staff and service users spoke well of the registered manager, appreciating his calm approach. One relative commented “We are very happy with the quality of care provided at 218 Stourbridge Rd. The team of staff under the leadership of Wayne Casey is dedicated and friendly …..”. The registered manager mainly worked office hours during the week to keep up with management work, but every other weekend worked on care duties within the home to keep in touch with service users. The registered manager had been working with his line manager towards finalising a quality assurance system for the home. The home had distributed their own questionnaires to service users and to relatives, but was intending to revise the questions to encourage a wider range of responses. They had also compiled a development plan for the home, based on feedback from questionnaires, on previous CSCI reports, and on CSCI guidance on assessing the quality of care homes (KLORA). They had almost completed work on selfassessment of how the home met National Minimum Standards. Health and safety was well managed in the home, but there were still difficulties with getting required work done by the Trust facilities department. There were records of up to date safety checks on gas, water and electrical equipment and installations. However the latest electrical installation test certificate from 2003 (normally a 5-yearly test) stated the condition was “Unsatisfactory”. The registered manager agreed to follow this up immediately to find out what work had been done in response (he had not been managing the home in 2003). The home had a full range of up to date risk assessments, dating from or reviewed during 2006 and covering the recommended safe working practice topics. Fire safety training for staff was up to date, though it was not apparent whether all staff had taken part in a fire drill during the past year. Fire safety tests and checks were up to date, except there was no evidence of emergency lighting being serviced. A problem with emergency lighting had been identified in October 2006, but the home was still waiting for the Trust to carry out appropriate work. In addition, the Fire authority had inspected the home in February 2006 and required some work. The registered manager said most had been done, but that the alarm panel had not been changed as the Trust facilities department had deemed it too expensive. This would seem to be a lax approach to service users’ safety from the Trust and is unacceptable. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 1 X Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 24 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 Requirement All entries on Medication Administration Records must be clear and unambiguous. Medication given must be consistent with instructions on medication labels and on MAR charts. Necessary maintenance and refurbishment must be carried out on the bathroom next to the upstairs office. (Previous timescales of 31/12/05 and 31/03/06 not met, but work planned for March 2007.) 4 YA34 19 The registered manager must ensure that all required information is available before staff begin working in the home. The draft quality assurance system must be implemented. (Previous timescales of 31/10/05 and 31/03/06 not me, but completion imminent.) DS0000061839.V312554.R01.S.doc Timescale for action 28/02/07 2 YA20 13 28/02/07 3 YA24 23 31/03/07 31/03/07 5 YA39 24 30/04/07 Stourbridge Road, 218 Version 5.2 Page 25 6 YA42 13, 23 The registered manager must find out whether the work specified in the electrical installation test certificate from 2003, which stated the condition was “Unsatisfactory”, has been completed. If it has not been completed, it must be done to ensure the home is safe. All staff must take part in a fire drill each year. The registered provider must carry out all necessary servicing and maintenance of the emergency lighting system. 31/03/07 7 8 YA42 YA42 23 23 30/04/07 31/03/07 9 YA42 23 The registered provider must 31/03/07 carry out all remedial work in the home, as specified by the Fire Authority in February 2006. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Any actions which are effectively a restriction, including accompanying a service user for their own safety and wellbeing, should be recorded in the service user plan and reviewed. The registered manager should check that all risk assessments are reviewed regularly. The staff team should consider ways to enable service users to make a greater contribution to bigger decisions about the running of the home. The registered manager should work with staff to discuss consistent ways of interacting with service users. DS0000061839.V312554.R01.S.doc Version 5.2 Page 26 2 3 YA9 YA7 4 YA32 Stourbridge Road, 218 5 YA34 The home should give consideration to training service users to enable them to take a greater part in staff recruitment. Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Stourbridge Road, 218 DS0000061839.V312554.R01.S.doc Version 5.2 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. 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