Inspection on 11/10/06 for Strensham Hill

This inspection was carried out on 11th October 2006.

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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Strensham Hill 20/08/09

Strensham Hill 19/08/08

Strensham Hill 20/02/08

Strensham Hill 10/05/07

Strensham Hill 05/04/06

Strensham Hill 12/10/05

Strensham Hill 27/04/05

Strensham Hill 11/11/04

Strensham Hill 24/05/04

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 Strensham Hill 1 Strensham Hill Moseley Birmingham West Midlands B13 8AG Lead Inspector Sean Devine Unannounced Inspection 11th October 2006 09:40 Strensham Hill DS0000016874.V311409.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 Strensham Hill DS0000016874.V311409.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. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Strensham Hill Address 1 Strensham Hill Moseley Birmingham West Midlands B13 8AG 0121 442 4580 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) enquiries@servolct.org.uk Servol Vacant Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years That the home can care for named resident over 65 years for reason of Mental disorder 1 MD(E). That the service user will have regular reviews to ensure that the home can continue to meet individual care needs. 16/5/06 Date of last inspection Brief Description of the Service: The home is a large house on the corner of Strensham Hill Road. It is close to local amenities such as shops and places of worship. Moseley and Cannon Hill park are within easy walking distance where there is a range of facilities. Within the home residents have their own rooms, and there are communal living and kitchen areas, as well as a self contained flat which provides an opportunity for more independent living. Residents, share communal bathing facilities. The main lounge is bright and airy, and faces on to Strensham Hill. The kitchen is to the rear of the property and has individual storage facilities for each resident. There is a garden to the rear of the property, which is private, residents make good use of it in the summer months. To the rear of the garden there is space for some car parking. The home is geared towards providing rehabilitation to residents with enduring mental health issues with a specific focus on the needs of Afro-Caribbean residents. The current scale of charge for the home as indicated in the pre inspection questionnaire is £495.00 per week. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection to the home; a random inspection was undertaken on the 16th May 2006 to determine whether any improvements had been made within staff recruitment practices and planning the care and support of residents. This inspection was unannounced and lasted seven hours. Four of the six residents met with the inspector at different times during the day and two residents aired their views and opinions of the home. Prior to the inspection a questionnaire was sent out, this was not returned but was found completed and available at the home. During the visit two residents completed a survey known as “have your say about…” and returned them to the inspector. The records about the care of two residents were seen and the inspector viewed all communal areas. The senior manager, acting care manager and support staff spoke with the inspector during the visit. Records regarding health and safety in the home were also seen. What the service does well: The home has good policies and practices to ensure residents are fully assessed before offering accommodation. Residents are provided with good information to help them choose if they want to live at the home. Most residents have lived at the home for several years and although they could not fully recall their experience of moving in, some did say it was their decision to move in. Following assessments of residents needs and abilities, some by other healthcare professionals the staff have written care plans and risk assessments in consultation with residents, these are clear and concise and guide residents and staff of what to do to meet needs and maintain life skills. Residents are encouraged to be active and to follow their chosen pathways in life, including education, leisure, friends and relationships and maintaining good health. To do this residents have weekly activity plans, which they have helped develop. Residents’ comments included, “I enjoy college, I have lots of friends there” and “I help with keeping the home clean and tidy”. Residents are well supported to have routine and as required access to community healthcare professionals, including mental health teams, GP and other primary care facilities, these arrangements help ensure residents healthcare needs are respected and promoted. Three residents indicated they are well and if they are concerned medical appointments are made. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 6 The home is well maintained; residents indicated it is kept clean and tidy and that they are happy with the home; especially its facilities and decoration. What has improved since the last inspection? What they could do better: Residents have raised complaints including not being kept upto date about the appointment of a new manager and not being able as yet to go on an annual holiday. These complaints were not logged or responded to, this must be improved and residents informed of how their concerns are being managed and what is being done about them. Some residents are at times hungry and asking other residents and staff for food, this must be improved to ensure residents are satisfactorily supported to have a healthy nutritional diet and that they are not hungry. Concerns and plans raised in some healthcare risk assessments including involving other healthcare professionals must be followed through to promote the health of residents. The home must ensure that staffing issues are quickly overcome as this is putting the residents at risk; the issues include safe recruitment, maintaining good staffing levels and good evidence of safe working practice training. At present residents are excluded from being involved with viewing their opinions as part of a quality assurance and reporting system, although they meet regularly their views and opinions are not being considered when it comes to making plans for continuous improvement. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 7 The home must appoint a new manager as the post is currently vacant and a senior member of staff is acting in the role. This manager must be given time within the working week to undertake management and administrative duties to ensure day to day operations are effective and timely in meeting the needs of the residents. At present the acting manager is having to spend much of the time as a support worker, covering sleeping in duties due to short staffing and has not been allocated time for managing the home. This is putting the health and safety of residents and staff at potential risk. 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. Strensham Hill DS0000016874.V311409.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 Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 2 The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The service clearly has the ability to ensure that residents are provided with information to make a decision on whether the home is suitable for them, they also ensure they have the capacity to meet the prospective residents needs before offering accommodation. EVIDENCE: Residents have been offered a copy of the statement of purpose and residents guide, some have declined however there is a communal copy available to all residents and interested persons in the hallway to the home. During the inspection two residents completed a survey called “have your say about…”, two residents indicated that they were asked if they wished to move into the home and that they were provided with information about the home. The residents who spoke with the inspector were not able to recall their experience of moving into the home, however they did indicate it was their decision to move in. Two residents records contained good information about their assessed needs, which were made available to the home prior to admission. Examples of these included case conference reports from forensic mental health teams and care Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 10 programming approach care plans and risk assessments completed by social workers. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to meet the assessed needs of the residents, to do this they have developed care / support plans and risk assessments in consultation with residents, which are clear, concise and informative to guide staff. EVIDENCE: Care and support plans for two residents were seen, all had been signed by residents and they were reviewed on a monthly basis. These reviews commented on how effective or otherwise the plan had been. The plans included specific guidance, which was written clearly and concisely for staff and resident to follow in order to meet the assessed need. One residents’ survey recorded that they can always make decisions about what they do each day and another recorded that this is sometimes. Residents were seen advising staff on their days plan; this was seen to mainly reflect each resident’s individual activity plan. One resident advised the inspector that there are few restrictions in the home. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 12 Personal risk assessments for two residents were seen, as with care plan these had been and agreed by the residents. They are normally reviewed every six months or sooner where needed. Examples of these are mental health relapse, safety in their rooms, self care (personal care), substance misuse and managing their finances; there were many other risk assessments and management plans relating to these residents. Daily records were seen that reflected upon the day’s events for two residents, these were informative and gave evidence that care plans and risk management plans are being followed. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15,16 and 17. The quality in this outcome area is poor. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to support the chosen lifestyles of some of the residents. However, the overall arrangements for activities and meals are variable and fails to meet all residents needs. The food budget places residents on the poverty line. EVIDENCE: Two residents described what they do at the home and within the local community, this included domestic activity, attending clubs, day centres and colleges, this echoed details in their individual activity plans. Residents were seen going out to local shops and also returning from their day at college. One resident told the inspector she has lots of friends and enjoys going to college. Another resident informed the inspector she had been involved in interviewing for a new manager at the home. There were many entries in the daily records that indicate residents shop for their own clothes, cosmetics and food. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 14 Residents meeting minutes record that they are unhappy with not having an annual holiday; the acting manager and a senior manager advised that on at least two occasions plans for the holiday had been submitted but were not authorised by the Chief Executive as she felt they were too expensive. A senior manager from the Servol organisation is currently making plans for a holiday to take place, she advised she will be speaking with the residents and the organisations committee. Mealtimes at the home are greatly varied, all residents are provided with breakfast normally cereals and toast, some residents who are out at college or day centres buy or are provided with their own lunch. Residents will often then cook at teatime or eat out. One resident requires all meals to be prepared and cooked by the staff at the home; they assist with a shopping list, do the shopping and then cook the meal the resident has chosen. A record of all food eaten by residents in the home is maintained. The Servol organisation provides each resident with £22 each week for food, this has remained the same amount for several years and a review of this amount should be considered; this is further supported by an entry in the residents meeting minutes that stated some residents should stop “begging” for food from other residents and the homes supply. On a Saturday the staff cook a communal meal provided by the Servol organisation after asking residents what they would prefer. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home does not at all times demonstrate its ability to meet the healthcare needs of residents, which may lead to poor care and put the health and well being of residents at risk. EVIDENCE: The staff at the home assist one resident with a lot of personal care, at present the increased dependency for this resident is being reviewed. Other residents require some minimal support with skin care, cosmetics and hairstyling as for some residents this may present a risk, to support this and reduce risk a management plan is in place. Two residents confirmed they see their GP and community psychiatric nurse when needed and one sees the nurse monthly. Health records on residents files indicate they are able to see a dentist, optician and if required receive a chiropody service. Some residents do have to pay to see a local chiropodist. Contact arrangements were confirmed in the pre inspection questionnaire. For one resident a risk assessment management plan included contacting a continence nurse for an assessment, this had not been completed. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 16 The management of medication for two residents was assessed. Records of when medicines are received and administered for these residents are well maintained. Medicines are prescribed by either the GP or from a doctor associated to the mental health teams; where the GP prescribes, copies of the prescriptions are available to check they receive the correct medication from the community chemist. This is dispensed in a monitored dosage system. Staff training records indicate that all staff have received training in how to safely manage this system. For one resident insulin is stored in a locked money box and kept inside a fridge in the kitchen, a separate medicine fridge is needed to store medicines. One resident told the inspector that the nurse visits monthly to give a depot injection. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. The quality in this outcome area is poor. This judgement has been made using available evidence and a visit to the home. The home has not demonstrated it has the ability to support residents to raise their complaints and to act appropriately when complaints are made, they also do not protect residents through the risk assessment process, which may lead to residents being abused. EVIDENCE: The surveys completed by two residents did not raise complaints or concerns, and they recognised how to make a complaint. The complaints policy is on display, it is also included within the statement of purpose and residents guide. Two residents who spoke with the inspector did not have any complaints. The minutes of residents meetings recorded two complaints from residents firstly, their unhappiness of not having an annual holiday and secondly, not being informed of how the recruitment of a new manager was progressing. These complaints had not been recorded within the log of complaints at the home and no acknowledgement or response to these complaints had been made to the residents. It appears that the home did not recognise them as complaints. The commission has not received any complaints about the home in the past twelve months. There were limited staff training records available, however a senior manager did provide certificates for some staff confirming they have recently attended training in adult abuse awareness and managing challenging behaviours. The senior manager advised that a programme to train all staff is in place. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 18 For some residents risk assessments about how their finances are managed are in place, yet for one resident it states that Servol manage the money and there is no management plan about how money is accessed by the resident and how checks are made to ensure it is safe. For this resident the balance of money in safekeeping was found to correspond with available records. Another resident has a risk assessment to ensure safety from abuse’ and managing difficult situations, however the management plan is poorly written and punitive measures are detailed, rather than how it is to be effectively and positively managed. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 27 and 30. The quality in this outcome area is good. This judgement has been made using available evidence and a visit to the home. The home has demonstrated it has the ability to maintain the environment to a good standard, residents are pleased with the homes facilities and how clean it is, to achieve this the home has involved the residents which promotes their well being. EVIDENCE: Residents who completed the survey advised that the home was kept fresh and clean. Two residents in conversation with the inspector were happy with the environment, one said “its nice and always kept clean”. A tour of the communal areas, including toilets and bathing facilities was undertaken. The garden is spacious and has adequate amounts of garden furniture for residents to enjoy the surroundings. The rear car park adjacent to the garden has some fence panels missing. The lounge area is well maintained, pleasantly furnished and well equipped. The kitchen is new, prior to the last inspection, it has been well maintained, and it is well equipped and provides individual residents with good food storage areas. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 20 The stairwell is in need of redecoration including painting to skirting and attention to worn and torn wallpaper. On the first floor there is a small shower room and a bathroom with a toilet, the skirting along the bath panel needs attention due to water damage. One resident who has increased personal care needs lives in a downstairs room, which has an en-suite toilet and shower facility. An upstairs toilet requires improved lighting as it is very dull. The laundry room is small but well equipped, the washing machine does have a sluice cycle and the floor is impermeable. Access behind the tumble dryer and washing machine is difficult, which has led to a build up of “fluff” behind these machines. All high-risk areas in respect of infection control including toilets, kitchen and the laundry have good hand washing facilities. Sanitary disposal is available in some of the toilets. A cleaning rota, which includes residents doing some chores is displayed and included as part of residents’ domestic activities. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34 and 35. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The home has demonstrated some improvement in its ability to ensure staff are fully checked to safeguard the residents, however it does not demonstrate its ability to provide residents with adequate numbers of staff who are at all times well trained to support residents. This may lead to poor care and put the health and well being of residents at risk. EVIDENCE: Staffing rotas are on display in the office, it was evident that this is a small team of staff and the acting manager is mostly included on the numbers and for sleeping in duties. Two staff should be on duty at all times, however as identified at previous inspections there are some gaps at busy times of the day when there is only one, for example the sleeping in member of staff commences duty at 8.30am and sometimes the second member of staff does not start duty until 10am. The staff rota on the wall did not fully reflect who had been working, it recorded “agency” when the inspector was informed that this was a “bank” member of staff and at times no names had been recorded against the shift that needed to be covered. At night there are no waking staff; one member of staff on a sleeping-in basis is available to residents. The residents survey did not raise concern about staffing levels. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 22 Four staff recruitment files were seen, three included some of the required checks such as criminal records bureau disclosures (CRB); the fourth did not include a CRB or POVA register check, the visiting senior manager advised that this was a bank staff who had worked across many services within the organisation for some years. The senior manager was advised that a POVA register check and CRB are required for this staff member. All staff files included application forms and where required written references, there was no evidence of health checks on any files. Following the inspection the senior manager was issued a letter of immediate requirements to ensure all staff have the required CRB and POVA register checks completed. Staff files contained some certificates of attendance on courses, however there was no adequate training record or a training matrix available. The acting manager and senior manager advised that some other certificates were at the head office. Those that were available included some evidence of fire safety training. The pre inspection questionnaire completed by the acting manager indicated that there are four care staff, this included the acting manager and that three of these staff had completed NVQ level 2 or above. There have been no new staff appointed at the home for some time and therefore the induction training of new staff could not be assessed. Strensham Hill DS0000016874.V311409.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. The quality in this outcome area is adequate. This judgement has been made using available evidence and a visit to the home. The ability of the home to effectively manage and administrate the day to day operations has not been demonstrated, there is no clear leadership and no formal system of quality assurance. At present the residents are excluded from viewing their opinions and the acting manager works predominantly as a support worker, this will have a negative effect on the management of care. EVIDENCE: Interim measures are in place to manager the home, the senior Servol manager advised that the acting manager has a level 3 NVQ in Care and has completed the level 4 Registered Managers Award. She also advised that the acting manager has approximately twelve years experience of working within mental health services both for Servol and prior to Servol in residential services. The acting manager at the time of the fieldwork had been in post two weeks. The staffing rota indicated that for many of her shifts she is Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 24 included as a support worker and undertaking sleeping in duties; time for carrying out management duties is not always recorded on the rota. Residents’ surveys indicated that the acting manager, as well as the staff treat them well and listen and act on what they say. A resident and the senior manager advised that interviews for a new manager had taken place however it appears as yet no appointment has been made. There has been no progress to develop a system of quality assurance that will provide an effective method of monitoring standards at the home, no formal consultation with residents has taken place and there is no quality report available to residents or interested parties. The residents do have a monthly meeting and the minutes are recorded, however there are concerns that these meeting are being used inappropriately as some residents are appraised for there efforts to keep the home clean whilst others are criticised, this has led to arguments amongst residents in some meetings. Some items on the agenda are very important to residents including holidays, new manager, new statement of purpose and residents guide, cooking and chores. Concerns and complaints raised by residents at these meeting are not always responded to as recorded in standard 22 Complaints. Management of health and safety records including risk assessments, servicing, maintenance and tests were seen for the premises, utilities and equipment. Gas and electrical tests and servicing are routinely completed. At the recent fire officers inspection concerns were raised that the fire risk assessment is not reviewed, that findings regarding compliance are not recorded, that an emergency plan is not available and that all employees should be trained. The fire risk assessment was seen however it had not been reviewed or updated to include requirements of the fire officers’ report. The senior manager and acting manager advised that some fire training records were at head office. It was evident that a weekly test of the fire alarm is conducted and that the emergency lights are checked monthly. Regular fire drills are completed and records of response, comments, who attended including residents and staff are maintained. Risk assessments were seen for food safety, building and staff, all were in need of a review. The staff at the home conduct a monthly health and safety checklist, however how this is conducted is a concern as on some occasions where staff had ticked to state compliance it was not evident for example, risk assessments had been reviewed and staff training (fire) was upto date, when no records were available at the home. Strensham Hill DS0000016874.V311409.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 1 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 2 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 2 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 26 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 YA14 Regulation 16(2)(m)(n) Requirement The registered person must ensure that residents have the option of annual holiday, which they help choose and plan. Residents nutritional needs must be fully risk assessed and include where needed education and support to eat a healthy diet. Previous timescale of 30/11/05 not met, this requirement has been carried forward. An urgent review of food budgets is needed to ensure residents do not go hungry The registered person must ensure that one resident who requires an assessment by a continence nurse / advisor as identified in the risk management plan has this completed. The registered person must ensure that a separate medicine fridge is provided and used. The registered person must DS0000016874.V311409.R01.S.doc Timescale for action 31/12/06 2 YA17 12(1) 13(4) 16(2)(I) 07/11/06 3 YA19 12(1) 30/11/06 4 YA20 13(2) 30/11/06 5 YA22 22(1)(3)(4) 30/11/06 Page 27 Strensham Hill Version 5.2 17(2) sch 4(11). 6 YA23 13(6) 12(1) 7 YA23 13(6) 12(1) 8 YA24 23(2)(b)(d) 9 YA33 17(2)Sch 4 (7) ensure that complaints made by individual residents or as a group are effectively recorded, managed and responded to. The registered person must ensure that risk management plans to help safeguard residents finances clearly describe how residents access their money and what safety measures are in place. The registered person must ensure that risk management plans to protect residents from abuse do not include punitive measures to reduce risk. The registered person must ensure that the minor repairs, maintenance and redecoration to the building as recorded within standard 24 of the report are completed. The names and hours worked at the home by all staff must be recorded upon the staff rota, including agency staff and bank staff. 31/10/06 31/10/06 31/12/06 31/10/06 10 YA33 18(1)(2)12(1) 13(4) Previous timescale of 31/05/06 not met, this requirement is carried forward. Staffing levels must be 31/10/06 reviewed should the amount of residents’ increase or the needs of residents change. There must at all times be adequate staff on duty to assist residents to meet their recreational and social needs, which includes weekends. Previous timescale of 31/05/06 not met, this requirement is carried forward. During day hours (from Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 28 11 YA34 19(1)(a)(b)(i) paragraphs 1 to 7 of Sch 2. 12 YA34 19(1)(a)(b)(i) paragraphs 1 to 7 of Sch 2. 8.30am onwards) there must be a minimum of two staff in the home. The registered person must ensure that as part of the recruitment process that all staff have a health check, evidence this has been completed must be available. The registered person must ensure that all staff who work at the care home have a CRB completed as part of the recruitment process. For one member of the bank staff a POVA register check must be completed. All staff must have received or have planned training for safe working practices and training to safely meet the specific needs of residents such as Mental Health Awareness. Previous timescale of 30/06/06 not met, this requirement is carried forward. The manager must receive regular supervision and records must be available. Previous timescale of 28/02/05 not met, this requirement has been carried forward. Not assessed at this inspection and is carried forward. The registered person must ensure that a competent, qualified and experienced manager is appointed. The registered person must ensure the acting manager is allocated adequate time to undertake management duties. DS0000016874.V311409.R01.S.doc 31/10/06 25/10/06 13 YA35 18(1)(c)(i) 31/12/06 14 YA36 18(2) 31/12/06 15 YA37 9(1)(2) 31/12/06 16 YA37 18(1)(a) 31/10/06 Strensham Hill Version 5.2 Page 29 17 YA39 24, 26 This must be reflective on the staff rota. The registered provider must make monthly visits, and reports of such visits must be made available at the home. A continuous self monitoring tool, using an objective, consistently obtained and reviewed and verifiable method (preferably professionally recognised quality assurance system) must be introduced. It must involve residents and have an internal audit, which takes place at least annually. Previous timescale of 31/03/05 not met requirements are carried forward. A report in respect of the quality review must be available to residents and the commission. The registered person must ensure that all improvements needed as identified by the fire officer in his report dated 27/7/06 are completed. The fire risk assessment must be reviewed, findings of compliance measures recorded and reference to the findings of the fire officers report made. The registered person must ensure that food safety and building risk assessments are reviewed. The registered person must ensure that the monthly health and safety check is completed only after checks of compliance 30/11/06 18 YA42 13(4), 23(4) 12(1) 30/11/06 19 YA42 13(4) 12(1) 30/11/06 Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 30 have been made and record the findings. 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 YA43 Good Practice Recommendations There should be a business and financial plan for the home and the service, available to CSCI for inspection and reviewed annually. Not assessed at this inspection and is carried forward. Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 31 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 Strensham Hill DS0000016874.V311409.R01.S.doc Version 5.2 Page 32 - 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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