Inspection on 17/12/07 for The Royd

This inspection was carried out on 17th December 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Royd 10/10/08

The Royd 20/10/06

The Royd 17/02/05

The Royd 28/06/04

The Royd 09/03/04

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 The Royd 27 Selbourne Road Handsworth Wood Birmingham West Midlands B20 2DN Lead Inspector Kerry Coulter Key Unannounced Inspection 17th December 2007 09:20 The Royd DS0000024885.V357156.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 The Royd DS0000024885.V357156.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. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Royd Address 27 Selbourne Road Handsworth Wood Birmingham West Midlands B20 2DN 0121 554 3544/523659 0121 554 8700 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) the.willows@ashbourne.co.uk West Regent Ltd Mrs Kay Marie McIntosh Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Physical disability (1) of places The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That the home can accommodate up to 16 adults of either gender with mental health problems (MD). 20th October 2006 Date of last inspection Brief Description of the Service: The Royd offers rehabilitative residential care for up to 16 younger adults with mental health problems and work closely with mental health rehabilitation and recovery teams. Accommodation is spread over two premises 23 - 25 and 27 Selbourne Rd on a core and cluster model. Extensive refurbishment, redecoration and building work has been completed leading to many of the residents returning to the home from Millwater Care Home (temporary accommodation) on the 10th July 2006. The premises are located next to one another on a residential street in Handsworth Wood and blend in well with other housing in the area. The home is conveniently situated for bus routes into Birmingham and around the city on the outer circle. All residents’ rooms are large single rooms with en-suite bathing and toilet facilities. There are some communal toilets in each house. Both houses have large-scale communal kitchen and smaller laundry facilities. The managers and administrators offices are sited on the 2nd floor of house 23 - 25 and small staff offices are located on the ground floor of each house. There are large lounge and dining areas in each house and both houses have enclosed rear gardens. Information from the service user guide indicates that the standard fee ranges from £407.82 to £1418.07. The fee information included in this report applied at the time of the inspection and the reader may wish to obtain more up to date information from the care service. Copies of reports from the CSCI are available at the home, on request. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out over seven hours, the home did not know we were coming. This was the homes key inspection for the inspection year 2007 to 2008. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a pre inspection questionnaire (AQAA). Three people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. Most people who live at the home were spoken to, however some people were out for part of the day. Discussions with staff took place and the Manager was available for the visit. CSCI survey forms were received from seven people who live at the home, three care professionals, two members of staff and one person’s relatives. What the service does well: The people who live there have their needs fully assessed and are involved in making the decision about living at the home. Each person who lives there has their own care plan and risk assessments. This gives staff the information they need so they can help people to meet their needs. Staff were observed to give support with warmth, friendliness and patience and treat people respectfully. Staff support the people who live there to go out and do the things they want to do. Staff support people to keep in contact with their family and friends. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 6 The people living there are encouraged to do things for themselves. They do their washing, ironing, clean their bedrooms, wash up and help to prepare their meals. Staff help them as much as they need to. The home has a satisfactory complaints procedure. One person said that if she is unhappy she speaks to staff and ‘they sort it out’. The home is “homely” and does not present as an institution, how it is decorated reflects a warm and relaxing atmosphere. All areas of the home were clean so it is a pleasant place for people to live in. There are usually enough numbers of staff on duty to support and care for the people who live at the home. They are safely recruited, which includes making checks on their backgrounds. Staff know the people who live there well and how to support them to meet their needs. What has improved since the last inspection? What they could do better: Care plans show some consultation with people about their views on the care they receive but is an area that could be further improved. Arrangements need to improve to makes sure people are supported to attend regular health checks, such as dentists and opticians. Some areas of medication practice needs to improve so that people get the medication they need, safely. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 7 The system for ensuring the gas safety check is done should be reviewed to ensure the check is done annually so that gas installations are safe. 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. The Royd DS0000024885.V357156.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 The Royd DS0000024885.V357156.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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements ensure that prospective service users have the information they need to make a choice as to whether or not they want to live there. Before a person moves in their needs are assessed so to ensure that they can be met there. EVIDENCE: It was observed that the Statement of Purpose and Service User Guide documents are readily available in the home. These documents were up to date and included all the relevant and required information to help people decide if they would like to live at this home. Six of the seven people who returned surveys said that they were given enough information about the home before they moved there. One person had moved in since the last key inspection. Their records showed that an assessment of their needs was completed before they moved in to ensure they could be met at the home. Another person was in the process of being assessed to see if their needs could be met, their records showed they had undertaken a trial visit to the home. One person who had moved into the home recently confirmed they had the chance to visit before they moved in. The Royd DS0000024885.V357156.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so they know how to support the people living in the home. Risk assessments generally ensure that risks to people living in the home are managed in a safe manner. People are consulted on how they wish care and support to be provided. EVIDENCE: The three people who were case tracked all had written care plans. These plans are generally reviewed monthly and include many areas of support such as mental health, physical health, support with managing finances and budgeting and personal care. One persons needs had recently changed and it was observed that staff were working on updating the care plans to ensure they reflected the support that the person now needed. Since the last inspection a form to establish people’s likes and dislikes has been introduced to contribute towards plans being more person centred. These have been completed for some people at the home and the Manager said that they would soon be done for everyone. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 11 All the care plans observed had been signed by the person. Records of review meeting were available, attended by the person, staff and usually the person’s social worker. These did show some consultation with people about their views on the care they receive but the recording of people’s views could be more detailed. At the last inspection it was observed that there was some inappropriate terminology used in some of the care plans. Plans sampled at this inspection did not have inappropriate terminology and were respectful of the person. Meetings are held on a regular basis with people who live at the home, issues discussed include activities that people would like to do, holidays and meals. Minutes of the meetings were available, it is recommended that a system is introduced that tracks the outcome of people’s requests at the meetings to make sure things get done. The majority of people who returned the survey confirmed that they can do what they choose during the week and at weekends. Records sampled included individual risk assessments. These stated how staff are to support the person to minimise the risks from manual handling, falls, self harm, mental health, roads and misuse of money. At the last inspection it was identified that for some people who at times require more support due to challenging behaviours a risk assessment was not available. These have now been completed. The Commission was notified about an incident where one person had been choking during a meal. Checking of the persons records showed that a risk assessment had been completed soon after the incident to try and reduce the likelihood of a re-occurance. One of the agreed measures to reduce the risk had been for the person to see their GP, however an appointment with the GP had still to be made two weeks after this was identified. Where actions are identified it is strongly recommended that timescales are set to ensure they are completed in a timely fashion. The Royd DS0000024885.V357156.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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the people living there experience a meaningful lifestyle. EVIDENCE: Records sampled and people spoken with indicate that people who live at the home have the opportunity to participate in an active lifestyle if they want to. One person said it was a good home and that they did their own food shopping and cooking. They said they did not go to college but did not want to go. One person said that they were doing computing at college and were really enjoying it. Some people at the home got involved in the company’s ‘Active in Bloom’(gardening) competition and came second, winning a voucher. One person who lives at the home said they had enjoyed this and it had inspired them to get voluntary work experience at a garden centre. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 13 Records sampled showed that other activities on offer include visits to the cinema, bowling, pubs, swimming and snooker. The Manager said that eight people who had wanted to go on holiday had been to Paignton. Some people enjoy doing in house leisure activities. One person said they liked playing scrabble and that staff had a game with them that day. Another person was observed doing some knitting. Many people enjoy watching the television but in house 25 the picture was observed to be of a very poor quality. A member of staff commented it had been like that for some time and gets worse during windy weather. This needs to be corrected to ensure people’s experience of watching the television is not spoilt. People who live at the home are encouraged and supported by staff to maintain contact with friends and relatives and a record is maintained of each persons contacts. Staff and people who live at the home said that a Christmas Party had been arranged and relatives and friends had been invited. It is good that a ‘relatives surgery’ is held six monthly by the Manager where relatives are invited to visit the home and discuss any issues they wish to with the Manager. People who live at the home confirmed they have opportunities to do their own food shopping and cooking. Some people prepare their shopping list and go out shopping with staff, other do this alone. Meals are managed in various ways, on a Monday, Saturday and Sunday staff cook a communal meal (paid for by the organisation), on Tuesday, Wednesday and Friday people prepare and cook their own meals out of the £20 given each week to each person by the organisation; on a Thursday, which is the training day people shop, prepare and cook a meal with a trainer from a college, this is paid for by the organisation. Food records show that people buy food that reflect their like and backgrounds however some people tend to cook microwave meals or have meals that are not too healthy such as burgers, chips and sausages. One professional who returned a survey was concerned that people often had frozen meals. Staff said that they do try and encourage people to buy healthy foods but people often choose not to. One person who lives at the home confirmed that staff do try and encourage healthy options. Fruit is readily available to people in the home if they wish to have it and people can choose from full fat, semi skimmed or skimmed milk. It is good that people are fully involved in choosing and cooking their meals but given that some people have a diet that is not that healthy staff at the home need to be more proactive in thinking of new ways to encourage people to have a healthy diet. The Royd DS0000024885.V357156.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvement is needed to ensure people’s health care needs are well planned for and responded to ensuring that their health is promoted. People who live at the home usually receive their medication safely and as prescribed by the GP but improvement is needed where people self medicate to ensure they are assessed as safe to do so. EVIDENCE: Most people who live at the home manage their own personal care, where people need support this is indicated in their care plan. It was evident that people are able to dress, use cosmetics and have hairstyles that are individual and of their own personal choice. The health care records of the three people case tracked were looked at. One person had some changing health needs due to having a previous fracture, it was observed that new care plans had been put in place regarding being unable to weight bear and pressure care. This person is currently receiving additional help from an Occupational Therapist and District Nurse. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 15 It was difficult from the records to establish when some people had last been to the dentist or the opticians for check ups. At ones person’s review it was recorded they had poor eyesight and there was a letter indicating they had an appointment at the eye hospital. It was unclear if the appointment had been attended. One person moved into the home in July but had not yet been supported by staff to register with a local dentist. The Manager will need to arrange for a full audit to be done to establish when people last attended health checks, and where needed make appointments for people to go. The weight of people are taken and recorded each month. For one person it was recorded that they had put on 10kg since July 2006. It was not clear from their care plans if they were still a healthy weight or if they now needed to lose weight to stay healthy. Records sampled showed that staff receive training in the administration of medication. Medication is stored safely, since the last inspection the home has had a new medication trolley that provides more space for storage. Medication administration records (MAR)were sampled and these included a photo of the person so that new staff do not get confused about who the person is when giving the medication. The medication records sampled had all been signed correctly and there were no gaps on the records. One person is prescribed an inhaler for asthma but this was not recorded on the MAR. The Manager said that the person administered this themselves and took it with them whenever they went out. Two staff spoken with were aware that this person used an inhaler. Observation of care records and discussions with the Manager indicates that an assessment of the persons ability to self medicate has not been completed. This must be done to ensure they know when to use the inhaler and how much to take. At the last inspection it was identified that one person had some medication on a “PRN” or as required basis, but there were no guidelines available for the staff who administer medicine. After the inspection guidelines were completed for that particular individual, however at this inspection another person who was prescribed medication on an ‘as required’ basis was observed to have no guidelines in place. The Royd DS0000024885.V357156.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that the views of the people living there are listened to and acted on. The people living there are generally protected from abuse, neglect and self-harm. EVIDENCE: The Commission has not received any complaints about the home in the past 12 months. The home has a complaints procedure and this is clearly on display in the home. Surveys received from people who live at the home indicated they know who to speak to if they are unhappy. One person said that if she is unhappy she speaks to staff and ‘they sort it out’. Two social workers commented that the home had responded appropriately to concerns. The home sends out its own surveys to relatives to seek their views on the service. Two relatives had raised some minor concerns in the surveys they returned. It was good that these concerns had been detailed in the complaints log and that they had been quickly responded to. At the last inspection it was identified that staff training records did not reflect that a programme to train the care staff in safeguarding vulnerable adults was in place. At this inspection records showed that staff have now done this training. It is good that staff who are employed in non-caring roles such as the maintenance person have also done this training. Records sampled included an inventory of the person’s belongings so that staff can keep a track of what the person has and if anything should go missing it would be easier to track this. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 17 The Manager is not the appointee for people’s monies but people are supported by staff to collect their monies from the Post office. There is a safe keeping service for small amounts of people’s money and risk assessments have been completed regarding the support people need with their money. Records were available to show when money held had been returned to the person for spending. Usually both the member of staff and the person sign the record but the record for one person had not been signed by them on the last four occasions. Another persons record recorded they had spent just over £48 pounds on a shopping trip but the person had not signed the record and there was no receipt to evidence the expenditure. Systems in place need to improve to ensure people’s money is more effectively safeguarded. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: The home has been fully refurbished to a high standard and house 23 and 25 operate as one house. Surveys received from people who live at the home said that the home was always clean, this was observed to be the case during the inspection. There are nine bedrooms across the ground and first floor, which are all en-suite. There is large lounge and dining room, a separate room designated as the smoking area and a fully enclosed and pleasant rear garden. Discussion with the Manager and observation of the smoking room indicates that this room needs redecoration following a water leak. The Manager confirmed that this was planned and had not been done sooner due to the plaster having to dry out. There is a large kitchen, which enables more than one person to prepare and cook food at anyone time. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 19 There is a small laundry room with a washing machine, tumble dryer and ironing facilities. The area is too small to use the iron and ironing board and this has to be done in other areas of the home. The washing machine has a sluice cycle if needed and there are good hand washing facilities. The second floor of house 23 – 25 provides offices for the manager and administrator and there is also a training / meeting room. The offices are accessed by stairs and do not allow the Manager to be easily available to relatives and other visitors to the home. House 27 provides seven people with bedrooms, all en-suite across the ground and first floor, there is a large lounge and dining area and a room designated for smoking close off the foyer area where there is also a staff office. There is a large kitchen and a small laundry room. The second floor provides staff with sleeping-in accommodation. In both houses there are communal toilets and all furniture and fittings were seen to be of a very good standard. There is level access for people with movement and mobility needs throughout the ground floor in both houses, this includes accessing all communal areas. The first and second floors in both houses can only be accessed by using stairs and would not be suitable for anyone with mobility difficulties. The premises were observed to be homely in style. It was made more welcoming by having photographs of people who live at the home and all the Christmas decorations that had been put up. Three bedrooms were observed and these were seen to be in good decorative order and personalised by the individual, reflecting their age, gender and culture. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 20 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it has the ability to ensure that people are supported by staff who have been safely recruited, who are well trained, available in good numbers and who are regularly supervised. This ensures people benefit from a skilled and competent workforce with their individual and communal needs being effectively met. EVIDENCE: The AQA Assessment completed by the Manager records that ten of the fourteen permanent staff have completed an NVQ in care. The remaining staff are currently undertaking an NVQ. The number of staff achieving NVQ exceeds the standard that at least 50 of staff have this and ensures that staff have the skills and knowledge to meet the needs of the people living there. One person who lives at the home said ‘staff are nice’. During the inspection staff were observed to treat people with respect. It is good that the home uses its own bank staff rather than agency staff to cover any staffing shortages. This means that people are usually supported by staff who know their needs well. Rotas sampled and support workers on duty at the time of inspection indicate that staffing levels are satisfactory to meet The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 21 the needs of people during the day and at night. However, House 27 is not full and staffing levels will need further review if more people move into the home. Two records of staff employed at the home were looked at. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken. This helps to ensure that ‘suitable’ people are employed to work with the people living there. Records showed that new staff complete an induction to the home. One staff spoken with said they got ‘lots of training’ another said ‘training is excellent, you get what you need’. Some requirements were made at the last inspection regarding training and records showed that staff have now had training in adult protection, challenging behaviour and mental health. The home has a training matrix and a training plan for 2007-08. These documents show that staff receive training in manual handling, first aid, food hygiene, non violent crisis intervention, health and safety, infection control, fire safety and diabetes. Many staff have also done dementia training although there are no people currently living at the home who have dementia. The Manager said that staff had received some basic information on the Mental Capacity Act at a recent staff meeting so they are aware of it and the implications for the people living there. This legislation requires an assessment of people’s capacity to be done if there is any doubt that the person does not have the capacity to make a decision about their health and welfare. If they are assessed as not having the capacity an Independent Mental Capacity Advocate (IMCA) can be appointed to help them with this. Minutes of staff meetings showed that they are held regularly so that all staff are kept updated with the changing needs of the people living there, ‘best practice’ and any changes happening within the organisation. Supervision records showed that staff had received at least six sessions in the last year to ensure they are supported and have the skills, knowledge and training they need to work with the people living there. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 22 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that the people who live there benefit from a well run home. The people who live there can be confident that their views underpin all self-monitoring, review and development by the home. Arrangements generally ensure that the health, safety and welfare of the people living there is promoted and protected. EVIDENCE: The Manager has been a registered manager for approximately five years managing residential care homes that provide support and rehabilitation for people with mental health needs. She has attended training courses specific to managing care homes, safe working practices and managing the care of people who live at the home. The manager achieved the Registered Managers Award in 2005. Throughout the inspection she was able to describe many of the needs of people at the home, direct and lead staff and had clearly developed a good relationship with people. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 23 The Operational Manager for the home usually visits the home monthly and writes a report of the visit, copies of the reports are usually sent to the Commission by the Manager. Some reports for visits were not available, the Manager said that she did not always get a copy of the visit, however reports were available for recent visits. A more detailed audit of the home was completed by the Operational Manager in October 2007, this covered areas such as medication, care planning and staffing. Where shortfalls were identified action plans had been completed to make sure things were addressed. Questionnaires are available for relatives and people who live at the home to complete about their views of the service. Since the last inspection the responses to questionnaires completed by relatives have been collated and these were generally positive. Where minor concerns had been raised these had been responded to. Two people who live at the home had completed a questionnaire that was in an easy to understand format, they had made no negative comments about the home. Fire records showed that staff regularly test the fire equipment to make sure it is working. Regular fire drills are held so that staff and the people who live there would know what to do if there was a fire. Staff test the water temperatures regularly to make sure they are not too hot or cold. Records showed that at the last test these were within the recommended safe limits so that the people who live there are not at risk of scalding. An up to date gas landlords safety certificate could not be located at the home during the inspection. A certificate was later forwarded to the Commission that showed a safety check had been completed a couple of weeks after the inspection week. Gas safety checks should be done annually and the check should have been done earlier, in August 2007. The system for ensuring the check is done should be reviewed to ensure it is done annually so that gas installations are safe. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 24 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 25 YES, number two. 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 YA19 Regulation 12(1) Requirement Ensure that arrangements are in place so that people are supported to attend regular health checks, such as dentists and opticians. Ensure that any medicines to be administrated to people as PRN or as required have guidance written for staff to follow so that people get the medication they need. Previous requirement, from 30/11/06. All medication prescribed to people must be recorded on their medication administration record so that staff know what each person is prescribed. Where people self medicate an assessment must be available to show they are safe to do so. Timescale for action 28/02/08 2 YA20 13(2) 28/02/08 3 YA20 13(2) 28/02/08 4 YA20 13(2) 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 26 1 YA6 2 3 4 5 6 7 YA7 YA9 YA14 YA17 YA19 YA23 8 YA42 Care plans and review meetings show consultation with people about their views on the care they receive but the recording of people’s involvement is an area that could be further improved. A system should be introduced that tracks the outcome of people’s requests at residents meetings to make sure things get done. Where actions are identified as part of the risk assessment process it is strongly recommended that timescales are set to ensure they are completed in a timely fashion. Action should be taken to ensure the picture quality of the television is improved to ensure people’s experience of watching the television is not spoilt. Staff at the home need to be more proactive in thinking of new ways to encourage people to have a healthy diet. Improve weight monitoring arrangements to clarify if people are a healthy weight and direct staff on the action needed where people have gained / lost significant weight. Where people are given personal monies held for safe keeping by the home then the person should be encouraged to sign for their monies, if they decline two staff should sign the record to make sure that people’s money is well looked after. The system for ensuring the gas safety check is done should be reviewed to ensure the check is done annually so that gas installations are safe. The Royd DS0000024885.V357156.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Royd DS0000024885.V357156.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!