Inspection on 19/08/08 for Strensham Hill

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Adequate service.

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 2 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 20/02/08

Strensham Hill 10/05/07

Strensham Hill 11/10/06

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 08/11/2008.

CARE HOME ADULTS 18-65 Strensham Hill 1 Strensham Hill Moseley Birmingham West Midlands B13 8AG Lead Inspector Gerard Hammond Unannounced Inspection 19th & 20 August 2008 09:30 th DS0000016874.V370441.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 DS0000016874.V370441.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. DS0000016874.V370441.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) Servol Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places DS0000016874.V370441.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 service user 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. 20th February 2008 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 service should be contacted directly for up to date information about fees and charges. DS0000016874.V370441.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the home’s first key inspection in the current year 2008-9. Information to inform the judgements made in this report was drawn from a range of sources. The Manager sent us a completed Annual Quality Assurance Assessment (AQAA). Two visits were made to the home and time spent talking to the residents and to the Manager and staff. A visit was also made to the organisation’s main office, to meet with the Acting Chief Executive Officer. We looked at records including personal files, health records, care plans, safety records, other documents and previous inspection reports. A tour of the building was also completed. Thanks are due to the residents, Manager and staff for their co-operation and hospitality throughout the inspection process. What the service does well: What has improved since the last inspection? A suitably qualified and experienced person has now been appointed to manage the home. Since coming into post she has begun work on reviewing and updating residents’ assessments and care plans, staffing, and information about what the service provides. Some of the repairs and maintenance work identified in the last inspection report have been completed. A new tumble drier has been installed in the laundry. Efforts have been made to ensure that vacant posts have been covered by staff whom the residents know, so as to promote some continuity of care. DS0000016874.V370441.R01.S.doc Version 5.2 Page 6 What they could do better: Most of these recommendations are carried forward from the previous inspection report. It has to be recognised that the home’s Manager, who has only recently been appointed, has not been in post long enough to be able to address these issues. Information about what the service provides needs to be updated. This is so people have current information to help them decide if the service is right for them. Work has already begun on this. Contracts also need to be brought up to date, so that it is clear what people’s responsibilities are. Care plans would be better if they were more detailed and “person-centred”. This means that they should focus more on each individual and what their goals are. It should be possible to see clearly whether or not people’s goals are being met. This would make sure that people get the support they want in ways that suit them. Plans should also include all of the important information that staff need to know to help people stay safe. Records about the activities people are able to do need to improve. These should be more detailed so that it’s clear how activities have been chosen and what people get out of doing them. Doing this will help to make sure that people can do the things that are important to them, and achieve their goals. Residents need to be better supported to make sure that perishable food they buy is used while it is still fresh. Records of the meals that people have eaten also need to improve: this is to make sure that people are consistently eating a healthy and nutritious diet, and help them manage this better. People’s healthcare could be managed better if all of the records were kept in one place. Each person should have a Health Action Plan to make sure they get all the support they need to stay healthy and well. A number of jobs need to be done around the house to make sure that it is well maintained and looked after. This will help to make sure that residents can feel comfortable and safe in their home. The staff team could be better supported. Vacant posts should be filled, and training and supervision better organised. This would make sure that staff have the knowledge, skills and support they need to do their jobs well. Action should be taken to make sure that the views of the people who use the service guide the way in which it is developed. DS0000016874.V370441.R01.S.doc Version 5.2 Page 7 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. DS0000016874.V370441.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 DS0000016874.V370441.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 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about what the service provides is available, but this needs to be updated. This will help people make an informed choice about whether or not the service is right for them. Residents’ needs have been assessed: some more work is needed to keep assessments up to date, so that people’s care and support can be properly planned. People should be given up to date contracts, so that all are clear about their responsibilities and what the service costs. EVIDENCE: There have been no new admissions since the last key inspection in February 2008, and the same five residents continue to live in the house. A new Manager has recently been appointed. She has begun work on reviewing the home’s Statement of Purpose and Service Users’ Guide. This should reflect the recent changes in the organisation, so that prospective service users have the most current information available. This was discussed with the Manager: the Statement of Purpose should contain all of the information shown in Schedule 1 of the Care Homes Regulations 2001. The Service Users’ Guide should be reviewed with reference to National Minimum Standard 1.2 (Care Homes for Adults 18-65). DS0000016874.V370441.R01.S.doc Version 5.2 Page 10 At the time of the last inspection it was noted that residents’ personal files contained assessments of their support needs, and that these were being kept under review as required. The new Manager said that she is conducting a review of all of the home’s care management processes, so that people’s records can be better organised and kept fully up to date. It was noted at the time of the last inspection that residents’ individual contracts were in need of updating, and a recommendation was made to this effect. It has to be acknowledged that the newly appointed Manager has not yet had time to address this issue, so the recommendation remains in place, as previously. DS0000016874.V370441.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, 8, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be developed, to make sure that people’s needs are met and risks are fully assessed. This will help to ensure that people get the care they need in ways that suit them best, and be supported to stay safe from harm. EVIDENCE: As reported above, the newly appointed Manager is reviewing care management practice in the home. However, the relatively short time since her appointment means that she has not yet had enough time to take this forward. At the last inspection it was noted that care plans continued to be in need of development, though some progress had been made in this area. Aspects that required continued attention included setting clear goals, developing person-centred approaches and reviewing risk assessments. Sampling of residents’ personal records showed that these issues continue to be in need of attention. DS0000016874.V370441.R01.S.doc Version 5.2 Page 12 Goals should have outcomes that can be clearly measured. People’s individual goals need to reflect their personal wishes and aspirations. It is important that each person’s plan shows clearly how goals are to be achieved. For example “live more independently” should show exactly what this means, and identify the steps to be taken to achieve it. It is also very important that goals are evaluated regularly, so that clear judgements can be made about what is working and what might need to be changed. In this way, people can be properly supported to do the things in their lives that are important to them. During discussions with the Manager, it was also recommended that the development of the use of “person-centred” approaches, should be taken forward. Doing this could help to ensure that the focus of care planning remains each individual concerned, rather than the needs of the service and the limits to what it can provide. Care plans and personal records show that residents are involved in day-today activities around the house, according to their individual abilities. These include taking responsibility for cleaning their rooms and some shared areas of the house, laundry and shopping. There is a rota for agreed tasks. Staff were observed supporting people to go out to the shops, sorting out their washing, and helping them make choices about what to eat and drink. A recommendation was made at the time of the last inspection with regard to risk assessing. There are risk assessments in place, but these need to be reviewed. This is to make sure that important information from the risk assessment process is included in people’s care plans. It was also recommended that clear indexing and cross-referencing of care plans and risk assessments would help to make sure this happens. In this way, the risk of hazards occurring can be kept to a minimum, so that people are properly supported to stay safe. DS0000016874.V370441.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents can do things they value, go to places they like and keep in touch with people who are important to them. However, planning of activity opportunities needs to improve in order to ensure that people can meet their goals. EVIDENCE: Discussions with residents showed that they are able to do things they value, go to places they like and keep in touch with their families and friends. People were observed doing jobs around the house, going out with staff to do their shopping and meeting their relatives. Records also show that some people go to local colleges and centres, go to the bank and post office, attend church, go out for walks and go to the pub or local restaurants for lunch. The quality of recording about what people do continues to be in need of improvement. Sampled files included activity plans: cross checking with what was recorded showed that what people actually did bore little or no relation to DS0000016874.V370441.R01.S.doc Version 5.2 Page 14 what was written in the plan. As reported previously, activities should be purposeful, and linked clearly to people’s assessments, care plans and agreed goals. The activity opportunities that people enjoy are prime indicators of their quality of life. If the stated objective of the service is to support people to live independently, then individuals’ activity programmes should reflect this. There are some examples of this in practice (e.g. jobs around the home, shopping etc.) but there is considerable room for improvement in this area. Supporting people to be as independent as they can be should include a range of opportunities both at home and out in the wider community. Planning for this needs to be more structured and clearly focused on individuals’ agreed personal goals. As previously recommended, developing the use of personcentred approaches in overall care planning and management could make a significant contribution to this. It has to be acknowledged that a particular feature of caring for people with mental health support can be problems with motivation. This may well be an issue when people are unwell or “low”. Good record keeping is an essential element of effective care management. Individual members of staff need to recognise their personal responsibilities in this area. The records they write should provide a true and accurate picture of what people do and / or their responses to being offered activity opportunities. These can then be used to help inform future planning, by identifying what works for people, and what does not. The quality of the records kept should be an issue for staff performance management, and dealt with through individual professional supervision, as appropriate. Staff also need to be clear about what individual residents’ agreed goals / objectives are: it is suggested that enabling them to play a more direct role in care planning could help to improve this situation. Each day residents choose what they want for breakfast and lunch if they are at home. They prepare this with staff support if required, according to individual needs. Staff cook a communal meal for everyone on four days each week. On the other days residents prepare and cook a meal individually, again with support as necessary. Staff support residents to shop for their groceries, so that people choose the food that they want to buy. Everyone has a designated space in the fridge / freezer and a lockable cupboard in which to store their food. It was difficult to make a fully informed judgement about people’s overall diets because the record of meals taken was incomplete. Food stocks were examined: these were plentiful and included a wide range of things, including fresh produce. However, it was noted that some of the perishable items kept in individuals’ personal stores were past their best. Opened packages of food were not labelled, so it was not possible to tell how long they had been stored. This was discussed with the Manager and it was agreed that a more systematic approach to monitoring this is required. However, it should be acknowledged that residents said that they liked the food they got and could have whatever they liked. They said that they particularly enjoy the Caribbean meals that staff cook for them. DS0000016874.V370441.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 adequate. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are met, but the management of their healthcare needs to improve. This is to ensure that they get all the support they need to stay healthy and well. EVIDENCE: Previous reports show that residents enjoy a good relationship with the staff that look after them. Direct observations of interactions between them provided further evidence of this. Support was given in a warm and friendly manner and people treated respectfully, as appropriate. Residents said that they liked the staff and got on well with them. People were appropriately dressed and had received the support they needed in their personal care. Sampling of people’s personal files showed records of appointments with health professionals and other members of the multi-disciplinary team. These included GP, Consultant Psychiatrist, Community Nurse, Dentist, Optician, Podiatrist and Chiropodist. There were records of reviews of people’s mental health carried out under the arrangements of the Care Programme Approach (CPA). DS0000016874.V370441.R01.S.doc Version 5.2 Page 16 However, it was suggested at the time of the last inspection that the way in which residents’ healthcare needs are planned and monitored was in need of early review. The newly appointed Manager has not been in post long enough to have an opportunity to do this, so this recommendation is carried forward. It was also recommended that Health Action Plans be developed for each person, and that all information relating to the planning, monitoring and delivery of their healthcare be stored in the same location on their personal records. Health Action Plans should show clearly what individuals’ health needs are, and include plans showing specifically how these are to be met. As with general care plans, these should have clear goals, with measurable outcomes and designated time limits. The focus should be proactive rather than reactive – that is “what needs to be done to promote this person’s good health and wellbeing”, rather than just “what needs to be done when a problem arises”. It should be acknowledged that elements of these were present in sampled care plans (for example, encouraging exercise, eating healthily) but more structure is required. This is to ensure that things that can be done to promote people’s good health actually get done, and that the situation is kept under regular review. The Boots Monitored Dosage System is used in the home for managing people’s medication. Copy prescriptions are kept on file: it was noted that no one is currently receiving PRN (“as required”) medication at this time. The Medication Administration Record (MAR) was examined and had been completed appropriately. The medication cupboard was clean and tidy and secure, as required. DS0000016874.V370441.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 adequate. This judgement has been made using available evidence including this service. Some people are happy that their concerns are listened to and taken Others may need more support to ensure that any concerns they raised and dealt with. Residents feel safe in their home and are protected from abuse, neglect and self-harm. a visit to seriously. have are generally EVIDENCE: The home shows that no complaints have been received since the last inspection in their Annual Quality Assurance Assessment (AQAA). We have not received any complaints in respect of this service, or notifications of any safeguarding referrals. At the time of the last inspection it was suggested that the service needed to develop a more open “complaints culture”. This is to ensure that people are actively encouraged to voice any concerns they might have, and get the support they need to do this. In discussion with the Manager it was suggested that this could be a standing item on the agenda for every residents’ meeting. Also, that individuals’ key workers could ensure that this was taken up with people on a one-to-one basis at regular intervals, and formally recorded. In this way, people who might be unsure or lack confidence to raise issues could be helped to speak up about anything that concerned them. It should be acknowledged that residents spoken to during the inspection said that they knew they had a right to complain if they were concerned or upset about anything. They were able to say to whom they would speak if this situation arose. DS0000016874.V370441.R01.S.doc Version 5.2 Page 18 At the last inspection it was noted that staff said they had received training in the protection of vulnerable adults from abuse. They were also able to show their understanding of relevant issues and of the importance of reporting any incident of actual or suspected abuse. The absence of a staff training and development plan meant that it was not possible to verify staff training in this area: this situation remains the same. Sampling of staff records showed that appropriate checks had been carried out with the Criminal Records Bureau (CRB), to ensure that people were fit to be employed. Residents said that they felt safe at Strensham Hill. DS0000016874.V370441.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, 26, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home are in need of attention, so that residents can enjoy living in a house that is homely and comfortable. EVIDENCE: A tour of the building was completed. At the time of the last inspection, a number of issues were highlighted as needing attention. The tumble drier has been replaced. The damaged floor covering in one of the resident’s bedrooms has also been replaced, and the carpet outside repaired. The damp patch on the ceiling above the stair well has been repaired, but some of the paintwork in this area is still flaking. It is disappointing to note that no action has been taken to replace the furniture in the lounge. This is now very damaged in places, with the outer fabric of the armchairs and settee worn right through. As previously reported, this detracts from the overall comfort of the residents, as well as the whole look of their main communal area. Two chairs in the hallway are still also in need of cleaning / reupholstering. DS0000016874.V370441.R01.S.doc Version 5.2 Page 20 All of the residents’ bedrooms were seen. Though individual, with personal possessions and effects in evidence, these too are looking “tired” and in need of redecoration. In addition to this, a small amount of attention and support from staff could help residents to make their rooms much more homely and comfortable. It was also noted that bathrooms and toilets, though fit for purpose and functional, would similarly benefit from a little extra attention. These improvements could provide excellent opportunities for residents to be involved in choosing colours and ornaments / decoration, making their home more personal and enhancing their sense of “belonging”. As previously stated, it should be acknowledged that the Manager has not been in post long enough to take up all of these matters. It should also be acknowledged that there have recently been changes to senior personnel within the organisation. This has meant that it has not been possible for the decisions needed to address these issues to be taken. These matters were discussed with the Manager and the Organisation’s Acting Chief Executive, who is now also acting as “Responsible Individual” for the service. (See section on Conduct and Management below also.) It is recommended that a maintenance and renewal programme be established for the home, so that necessary repairs and refurbishment can be planned and implemented appropriately. The home was generally clean and tidy, with an acceptable standard of hygiene maintained. DS0000016874.V370441.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 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to arrangements for staff supervision, training and development. This is to ensure that staff have the support, knowledge and skills they need in order to do their jobs well, for the benefit of the people in their care. EVIDENCE: Staff files were sampled. These contained copies of completed applications, two written references and evidence of checks with the Criminal Records Bureau (CRB). Examined files also contained copies of job descriptions, declarations of medical fitness to perform allocated duties, and copies of qualification / training certificates. Two files for people currently working in the home were not available for inspection. However, it should be acknowledged that both members of staff have worked for the organisation for several years at different locations. Both had been “drafted in” to support the existing care team since the last inspection. Their files were made available on request, and contained all required documentation. DS0000016874.V370441.R01.S.doc Version 5.2 Page 22 Particular efforts have been made to cover vacant hours using familiar staff from the organisation’s relief team (Staff bank) or agency personnel that have worked at the home before. The newly appointed Manager said that the staffing arrangements for the home are currently under review, and the subject of discussion with senior managers. It is recommended that the review of staffing be completed at the earliest possible date, so that vacant posts can be filled appropriately. This should promote continuity of care more effectively. At the time of the last inspection it was noted that staff covering the late shift (3.00 pm – 11.00 pm) then did the sleep in and the following days early shift (8.30am – 4.30 pm). She acknowledged that this is not best practice, and said that this is already an identified priority for attention. The Annual Quality Assurance Assessment (AQAA) shows that staff are trained to NVQ level 2 or above, and that training provided meets national standards and statutory guidelines. As reported above, sampled files contained evidence of people’s qualifications and training. However, the lack of a proper training and development plan for the staff team makes it difficult to assess fully the effectiveness of the training programme. It is recommended that people’s qualifications and training certificates are properly indexed on their personal files, for ease of reference. As recommended at the last inspection, a spreadsheet or chart covering staff training and development should be set up. This should show (for each member of staff) training completed and qualifications gained (with dates), gaps in training including “refreshers”, and dates when outstanding training is to be delivered. It was suggested that doing this could provide the Manager with an effective tool for monitoring and updating the training and development needs of the staff team. It was also reported at the time of the last inspection that arrangements for the formal supervision of staff needed to improve significantly. This continues to be the case: sampling of staff files showed little evidence of recording in this regard. However, it should be acknowledged that staff indicated that they were able to get support and advice on a day-to-day basis. The relatively small size of the home facilitates this. People said that the team worked well together, and that they tried hard to support each other, for the benefit of the people in their care. The Annual Quality Assurance Assessment (AQAA) shows that staff supervision is an identified area for improvement, and the Manager confirmed that this is a clear priority. As before, it has to be acknowledged that she has had little time in post to begin to address this effectively. DS0000016874.V370441.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, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager must now ensure that necessary improvements to the way in which the service is run are put into practice. This will ensure that the home operates in the residents’ best interests, and that everyone is supported to stay healthy and safe. EVIDENCE: There have been significant changes to this service since the last inspection in February 2008. Unfortunately, the organisation’s Responsible Individual was away from work for the last three months. This has affected the timing of action needed to address issues raised in the last inspection report. This person has now left the organisation. The Acting Chief Executive Officer is now currently carrying out the role. Since taking on this responsibility, he has been DS0000016874.V370441.R01.S.doc Version 5.2 Page 24 conducting a review of the service with colleagues. An experienced Manager from another part of the service has been drafted in for the last month to supervise the home. However, a qualified manager has now been appointed, and has recently taken up her post at Strensham Hill. She holds the Registered Manager’s Award (RMA) and a Masters degree in Business Administration (MBA). The Acting Chief Executive Officer and newly appointed Manager were both interviewed as part of this inspection process. As stated elsewhere in this report, it has to be acknowledged that neither has been in post for a sufficient length of time to fully address the issues raised at the time of the last inspection. However, conversations with both of them show that they have a good understanding of the things they need to do to improve the service. Both are currently engaged in assessing and agreeing priorities for taking the service forward. These include reviewing the staffing arrangements for the home, developing a clear strategy for care management and residents’ support, adapting work practices and ensuring that staff have clear direction, appropriate supervision, and the support they need to do their jobs more effectively. A requirement was made at the last inspection that visits on behalf of the Registered Provider required under Regulation 26 (Care Homes Regulations 2001) must be carried out each month. A written report should be made of each visit, so that an informed judgement can be made about the standard of care being provided in the home. This requirement remains outstanding. However, the Acting Chief Executive Officer was able to produce the new format he has devised for this purpose since taking up his position, and said that he would ensure that this was put into operation without further delay. Minutes of residents’ meetings were available for inspection. These show that meetings take place regularly (most months), but it was noted that the agenda for these meetings is quite limited. It was suggested (as reported above) that this should include a specific item to encourage residents to raise any concerns they might have. This should form part of the home’s quality assurance and monitoring procedures. These need further development, so that it is clear how residents’ views have been taken into account in the monitoring, review and development of the service. Safety records were sampled. The fire alarm and emergency lighting systems have been checked regularly and a written record of tests maintained. Fire fighting equipment has been serviced and a fire risk assessment is in place. This was undated, but information within the report suggests this was done 12 months ago and is therefore now due to be reviewed. Two fire evacuation drills have been carried out in the last six months. The Landlord’s Gas Safety and Electrical Circuit (5 year) Certificates are both in date. The COSHH cupboard was secure, as required. The accident report book was examined. Three reports have been filed since the last inspection. However, it was not possible to track these, as there was no indication of the people to whom they related. It is recommended that the counterfoil stub in the report book be noted with DS0000016874.V370441.R01.S.doc Version 5.2 Page 25 the initials of the person concerned and the date of the report, which should then be kept on the relevant personal file. DS0000016874.V370441.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X 2 3 X DS0000016874.V370441.R01.S.doc Version 5.2 Page 27 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 YA36 Regulation 18 (2) Requirement Timescale for action 30/11/08 2. YA39 26 You must ensure that staff receive formal supervision so that they have the support they need to do their jobs well. (Previous timescale 30/04/08 not met) 31/10/08 You must ensure that monthly, unannounced visits are made to the home on behalf of the Registered Provider, and a report written on the outcome of each visit. This is so that an informed judgement can be made about the quality of care provided in the home. (Previous timescale 30/04/08 not met) DS0000016874.V370441.R01.S.doc Version 5.2 Page 28 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 YA1 Good Practice Recommendations You should update the home’s Statement of Purpose and Service Users’ Guide so that current information is available to prospective service users. You should update contracts so that all parties are clear about what they are responsible for. You should ensure that all care plans reflect people’s personal goals, which should have outcomes that can be clearly measured. This is so that people can see whether or not goals set have been achieved, when plans are reviewed. Develop the use of person-centred approaches in order to make this happen. You should ensure that important information from risk assessments is included in people’s care plans. Clear indexing and cross-referencing would help to make sure this happens. This is so that the risk of hazards occurring is kept to a minimum, and people are properly supported to stay safe. You should ensure that recording of people’s activities is done in sufficient detail to show how choices were made, the purpose of the activity and what was gained from it. Show clear links between activity opportunities and people’s agreed goals and care plans. Doing this will help people achieve their goals and improve their quality of life. You should make sure that proper arrangements are made to support residents to keep perishable food fresh, and to keep a full record of the meals they have. This is to ensure that they eat a healthy and nutritious diet regularly. You should develop Health Action Plans for each individual, to make sure that their health care is planned and provided for systematically. This is to make sure that people receive all the support they need to stay healthy and well. 2. 3. YA5 YA6 4. YA9 5. YA13 YA14 6. YA17 7. YA19 DS0000016874.V370441.R01.S.doc Version 5.2 Page 29 8. YA22 You should ensure that everyone using the service is actively encouraged to voice any concerns. Having this as a standing item on the agenda for residents’ meeting could help to achieve this. This is so that the service can make sure that concerns are being addressed. You should put in place a maintenance and renewal programme for the home, and ensure that maintenance, repair and refurbishment detailed in the main body of this report, is carried out without delay. This is to make sure that residents can enjoy living in a house that is comfortable, homely and safe. You should recruit to vacant posts in order to bring the care team up to complement, so that continuity of care is promoted for the residents’ benefit. You should complete a training and development plan for the staff team, to ensure that staff have the knowledge and skills they need to do their jobs. You should ensure that all members of staff receive regular formal supervision, with written records kept of each meeting. Staff should also receive an annual appraisal of their performance. This is to make sure that they get the support they need to do their jobs well. You should ensure that the system for evaluating the quality of the services at the care home is fully implemented, and a written report of the outcomes made available to all interested parties. This is so that it can be seen that the views of people who use the service underpin the way in which it is reviewed and developed. 9. YA24 10. YA33 11. YA35 12. YA36 13. YA39 DS0000016874.V370441.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000016874.V370441.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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