Inspection on 20/10/06 for The Royd

This inspection was carried out on 20th 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 no outstanding requirements from the previous inspection report, but made 14 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 17/12/07

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 Sean Devine Key Unannounced Inspection 20th October 2006 09:25 The Royd DS0000024885.V311417.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.V311417.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.V311417.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 4732 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) Exceler Healthcare Services Limited Mrs Kay Marie McIntosh Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places The Royd DS0000024885.V311417.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). 7th July 2005 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. The current scale of charges to receive this service ranges between £399.82 and £708.96 each week; this information was provided by the home recorded upon the pre-inspection questionnaire. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection to the home was undertaken unannounced by one regulation inspector over one day. The inspector spoke to most residents, visiting relatives, the management team, administrator and some of the support staff. Prior to the inspection eight residents completed and returned a survey to the Commission known as “have your say about…” often making comment about their views and opinions of the home. The manager returned a pre-inspection questionnaire about the home, including information about the premises, residents, staff, community healthcare facilities, policies and procedures. During the inspection visit, records about healthcare and support to three residents and health and safety practices in general were seen and communal areas of both houses were viewed. Other records were seen including the management of complaints; the home has had one since returning to The Royd, which was effectively managed by the area manager and a response was made to the complainant. The commission has not received any complaints about the home since its return from Millwater. What the service does well: This home has ensured that a robust admission process is in place; this has involved the residents and many other health and social care professionals. Residents’ comments about returning to the home included “its fantastic to be back” and “I really like my new room”; relatives were also very positive about the return back to The Royd, comments included “its very nice accommodation”. Residents are being supported to lead active lifestyles, they each have individual activity plans based upon their choices, backgrounds and cultures; for example some residents are going to church, some go to day centres that provide activities they are interested in, other residents attend colleges, day centres and are others do part time jobs. One resident commented, “I am kept very busy” and “I enjoy cooking lessons” whilst one relative commented “I believe he is as well as he’s been for along while, due to being kept active and interested in hobbies”. This is very positive for residents and provides them with stimulating and purposeful lifestyles. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. 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 ensure residents can make a choice on whether they would like to live at the home and also decide whether they can meet the assessed needs of residents. This is positive and clearly informs the resident of the service they will receive. EVIDENCE: Three residents advised the inspector that they were often kept informed of when or if they would return to The Royd, they discussed meeting their social worker about the return and felt it was an anxious time waiting to here if they would return. This was due to the home no longer providing nursing care. Records were available on three residents files indicating a multi disciplinary assessment (including residents, staff from the home, relatives, social worker and psychiatrist) about the needs and support required for each resident and whether residential care could provide this. The surveys returned by the residents all record they were asked if they wished to move into the home and most record that they were provided with enough information about the new home and residential service, one resident did comment “I did not have enough time to prepare for the move, like the things I could have in my room”. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 9 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 adequate. 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 individual needs and to promote some choices for residents, however they do not always include the resident and specific risks to individual residents are not always well planned only increasing the risk to the residents well being. EVIDENCE: The three residents who were case tracked all had written care plans. These had been developed from assessments conducted by the home, from Care Programming Approach assessments, care plans and reviews and from social workers assessments and care plans. Three residents described their activity plans with the inspector and were clearly pleased that they were leading active lifestyles, they were aware of the activity plans and what they were to do each day. The written care plan did describe to staff the goal and objective of the plan, how it is to be achieved and who is to achieve it. These plans are reviewed monthly and include many areas of support such as mental health, physical health, support with managing finances and budgeting and personal care. Most care plans seen had not been signed by residents and it was not The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 10 evident they had been involved in the reviews. The home for some residents had also completed draft care plans to help guide residents and staff to meet the temporary needs of residents during the transfer from Millwater back to The Royd. Daily records made by staff are well written they provide evidence that the care plans are being followed and reflect the many activities of residents. Some of the terminology used in care plans needs improvement such as describing a resident as being “lazy” this does raise a question about the attitude or knowledge of some staff; other improvements such as who is responsible for actions such as taking blood pressure must also be recorded. All residents who returned the survey confirmed that they can do what they choose during the week and at weekends. Some residents and relatives commented that residents manage their own money. For residents that require some support with budgeting and managing their finances a risk management plan is needed to detail why is it a risk and what measures are in place to improve the financial safety for residents. Residents stated that what they say is acted upon by the staff an example of this was a resident strained his back and the staff arranged for a GP to see the resident and another resident was really pleased with the en-suite facilities in his room and that he can choose a bath or shower where as previously he was limited to the communal shower. The care records for residents did contain some personal risk assessments either written by the home or by community healthcare professionals such as by Rehab and Recovery mental health teams who identify the risk and indicators of mental health relapse and inform the staff at the home of their responsibilities. Examples of risk assessments used by the home, which have a limiting or restrictive impact on the lives of residents are fire safety and healthy eating due to hypertension. However for some residents who at times require more support due to challenging behaviours a risk assessment was not available. Two residents indicated they had been involved in planning their care as staff had approached them. Two relatives confirmed that they are frequently involved in and kept informed of the changes to care plans and risk assessments. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 11 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 12,13,15,16 and 17. 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 needs of residents, each residents lifestyle needs are assessed and individual activity plans are developed and implemented, this ensures residents are encouraged to be active and lead a purposeful life. EVIDENCE: Three residents, two relatives and the management team at some point during the inspection visit passed positive comments on how active the residents are now they have returned The Royd. This was further supported by the individual activity planners of residents that reflect such activities as cookery classes, relaxation sessions, trips to cinema, snooker halls, bowling and also to shops for food. One resident told the inspector he was learning so much about food and was really enjoying cooking. Two residents and a relative informed the inspector that the Birmingham Industrial Therapy Association (BITA) had been a positive experience. Relatives are encouraged to provided The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 12 appropriate support for residents where this is what the residents wish, one resident has been visiting his family as part of his activity planner, another resident described the regular visits of his sister and mother and relatives visiting at the time of inspection were happy with visiting arrangement and declared that visits can be in private. There are some routines and restrictions, for example residents are expected to follow their individual activity planner and in both houses can only smoke in the designated smoking room. Residents were seen to have unrestricted access to all parts of each house other than in each others bedrooms. Daily records seen for three residents do record their eating habits, for some residents where what they eat has a direct impact on their health, risk assessments are in place. To further ensure safety some residents 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 and residents cook a communal meal (paid for by the organisation), on Tuesday, Wednesday and Friday residents prepare and cook their own meals out of the £20 given each week to each resident by the organisation; on a Thursday, which is the training day residents shop, store, prepare and cook a meal with a trainer from a college, this to is paid for by the organisation. During the day residents who go out are provided with money for their lunch, including those that attend BITA, college and day centres. All residents across both houses are provided with large storage cupboards in each kitchen, they also have compartments in the fridge and freezer; lots of food was seen in both houses. On a Monday, Saturday and a Sunday residents can have a cooked breakfast if they wish to. It was evident that residents buy food that does reflect their likes, background and health needs. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 13 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 has demonstrated it has the ability to be mostly effective in meeting the personal and healthcare needs of residents, yet at other times some poor practices with managing medicines may put healthcare needs of residents at risk. EVIDENCE: Most residents manage all their own personal care; a risk assessment for one resident about mental health relapse included monitoring personal care as an indicator of relapse. It was evident that residents are able to dress, use cosmetics and have hairstyles that are individual and of their own personal choice. Healthcare records were available on residents’ files, these have recently been transferred onto Southern Cross forms, and older records have been archived. It was recorded that residents have seen their doctor, community psychiatric nurses and social worker. Two residents informed the inspector that staff have advocated for them and arranged healthcare, and one relative was pleased with how staff have responded when needed, this relative believes the staff to be experienced and competent in how they manage the healthcare needs of The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 14 residents. The weight of residents are taken and recorded each month, concerns where identified are discussed with the resident and if need be other healthcare professionals are informed. Since returning from Millwater to The Royd the home has changed its registration and no longer provides a nursing care service. All residents were assessed by a multi disciplinary team of healthcare professionals to identify the service each resident needed, the majority of residents did return to The Royd. At present the home is considering two residents who at present may be able to manage their own medicine. The manager advised that this would be done safely and follow a risk assessment. Medicines are either prescribed by the GP or by a doctor from the community mental health teams. Where the GP prescribes, medicines are dispensed by a high street chemist, using a monitored dosage system (MDS) and where prescribed by mental health teams these are dispensed into a medi-dose system. Stock control was normally good however for one resident it was inaccurate. All medicines in the MDS had been signed for when received into the home and when administered to residents. The tablets dispensed in the medi-dose system had not been recorded as received. One resident has some medication on a “PRN” or as required basis, yet no guidelines are available for the staff who administer medicine. The home does have a medicines policy, however it did not describe how staff manage as required medication and did not describe the need for guidance when such medicine is prescribed. Once the cycle of medicine is complete and if any medicines are still in stock the home completes a medicines return book and sends them back to the chemist. Training for staff in the safe handling of medicines is being arranged and the manager has arranged for a CPN to come and talk to staff about safe practices. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence and a visit to the home. The home has fully demonstrated it has the skills and processes to support residents and their representatives to raise and manage complaints. Yet there are concerns that staff are not trained to protect vulnerable adults and would not always know what measures they must take to protect the residents. EVIDENCE: The home does have a complaints policy and this process was followed when the home received a recent complaint. The complaint was acknowledged and investigated with a response to the complainant within the 28 days given. Records are well maintained at the home. The commission has not received any complaints about the home in the past 12 months. Residents and relatives who spoke with the inspector did not have any complaints or concerns. The home does have a policy for the protection of vulnerable of adults. Staff training records do not reflect that a programme to train the care staff is in place and the training event is not recorded on the staff-training matrix. The manager advised that the training is being arranged. There is a safe keeping service for small amounts of residents’ money. Records were well maintained, staff and the residents signed all money in and out of the account and the balances were found to be correct. However as recorded under standard 7 it is unclear why the home needs to do this as no risk assessments to suggest why residents were at risk and needed such a service were in place. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 16 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 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 that it does have the ability to provide an environment that meets both the individual and collective needs of residents, this will both help motivate residents and support their recovery and rehabilitation. EVIDENCE: The home has been fully refurbished to a high standard and house 23 and 25 now operate as one house. There are nine residents’ rooms 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. There is a large kitchen, which enables more than one resident to prepare and cook food at anyone time. There is a small laundry room with a washing machine, tumble dryer and ironing facilities. The area is too small for residents to use the iron and ironing board and they will need to use other areas of the home. The washing machine has a sluice cycle if needed and there are good hand washing facilities. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 17 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 residents, relatives and other visitors to the home. House 27 provides seven residents with rooms, 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 laundry is very small and some items stored in the room prevent safe access to the wash hand basin and also the washing machine. The manager was arranging for these items to be stored elsewhere. As with house 23 – 25 the laundry room on house 27 is small and residents have to find other areas of the home to iron their clothes. 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 residents 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. Residents commented “its fantastic to be back, I really like it”, “I really like my room” and “I have a nice view over the back garden”. Relatives comments included “I am very pleased about the new home” and “it is very nice accommodation”. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 18 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 it has recruited staff safely and provided adequate numbers of staff to support residents, however due to lack of staff training the standard of care may vary and residents needs may not be effectively met. EVIDENCE: Residents and relatives commented on the abilities of the support workers one resident said “they do a good job”; all residents who returned the “have your say about survey..” indicated that the staff treat them well and that they have no concerns. The pre-inspection questionnaire completed by the manager recorded that of the fifteen support workers 73 had completed the NVQ level 2 award or above. At present there are nine residents accommodated in House 23 – 25 and there are two support workers on duty between 9am and 9pm, and one during the night. On House 27 there are currently three residents, these residents are supported by one support worker day and night. At night there is at present one sleeping-in support worker based in House 27, available if needed to support staff in each house. The staffing levels on House 27 are currently The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 19 adequate but must be reviewed should the numbers and needs of residents change. Two staff recruitment files were sampled, both contained evidence of all required pre employment checks, an application form, interview records and for some staff up to date visas. The manager provided a training matrix for inspection, it was evident that there are gaps in some areas of safe working practices such as moving and handling and health safety training and also gaps in training specific to the needs of the residents such as the protection of vulnerable adults and mental health awareness. The manager advised that some training had been arranged and that she was in the process of arranging further training. Some staff had recently completed fire safety training and a further session had been arranged for November 2006. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 20 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 home does demonstrate it is generally well managed and that safety is important, yet it does not demonstrate it actively consults residents about their views, which may mean that what is important to residents about receiving a good service, is not considered. EVIDENCE: The manager had been in post prior to the residents returning from Millwater care home. She had been a registered manager for approximately four years managing residential care homes that provide support and rehabilitation for residents with mental health needs. The manager achieved the Registered Managers Award in 2005. The manager provided an up to date CV, which indicated that since 2001 she has attended a great deal of training including Health and Safety for Home Managers, Employment Law and Mental Health Awareness. She has attended many more training courses specific to managing care homes, safe working practices and managing the care of The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 21 residents. Throughout the inspection she was able to describe many of the needs of residents, direct and lead staff and had clearly developed a good relationship with many of the residents. Relatives commented “she is a good manager, always approachable and I have confidence in her”, residents commented that “she is nice” and “she has started a lot of activities and keeps us busy”. The home does have an internal policy about quality assurance and regularly audits many areas of the service, including kitchen, accidents, medication and complaints. The procedure also described an on-going monthly audit to assess satisfactory operation of the home by the operational and home manager, however it is not always evident how residents are consulted. The residents are invited to monthly residents meetings; the manager advised that participation does vary. Minutes of these meetings are available, however it is apparent that the meetings are importantly used as information / briefing meetings to inform residents about changes and new practices rather than to consult them on their views and opinions. The manager does have questionnaires for residents and relatives to complete, which will share their views and opinions about the standards of services and support at the home. The manager advised that the last questionnaire was issued to relatives in May 2006 that eleven were sent out, however she is unsure what came of them. The focus of this inspection in respect of health and safety was about fire safety, a fire risk assessment was not immediately available at the home yet the manager advised that it had been completed, shortly after the inspection a copy was sent onto the Commission. A gas landlords safety certificate could not be located at the home and a copy must be forwarded onto the commission. Fire alarms and emergency lights are regularly tested and fire drills are being carried out. The fire officer last visit dated the 20th September 2006 required the home make improvements, a letter was seen informing the fire officer that the required improvements will be made in timescale. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 1 YA6 15(1) The registered manager must 31/12/06 ensure residents and or their representatives sign their written care plans. 2 YA6 15(2)(b) The registered manager must 31/12/06 (c)(d) ensure that residents are involved in reviewing their care plans, that they are able to comment on how effective they believe the care plans to be and that this is recorded. 3 YA6 12(4)(a) The registered manager must 30/11/06 12(5)(b) ensure that support workers do 15(1) not use destructive and negative words in the residents care plans. 4 YA6 15(1) The registered manager must 30/11/06 12(1) ensure that written care plans fully describe the roles of other healthcare professionals involved within that written care plan. 5 YA9 15(1) The registered manager must 30/11/06 12(1)(2)(3) ensure that where residents 13(6) require support by the home to help manage their finances that a risk assessment is written to indicate why and what measures are in place to support residents. 30/11/06 6 YA9 15(1) The registered manager must 13(6) ensure that all residents who 12(1) present with a challenging behaviour(s) have a risk assessment written after consulting the individual resident about how this can best be safely managed. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 25 7 YA20 13(2) 8 YA20 13(2) 9 YA20 13(2) 10 YA20 13(2) 11 YA23 13(6) 18(1)(c)(i) 12 YA35 18(1)(c)(i) The registered manager must ensure that accurate stocks of medicines are maintained in the home for all individual residents at all times. The registered manager must ensure that all medicines when received into the home including those in a medi-dose system are fully recorded. The registered manager must ensure that any medicines to be administrated to residents as “PRN” or “as required” have a guidance written for staff to follow. The registered manager must ensure that the medicines policy describes all current practices and that it includes the need for PRN guidance for staff to follow. The registered manager must ensure that all support workers and senior members of staff attend a course on protecting vulnerable adults from abuse. The registered manager must ensure that all staff (including support workers) attend training in all required safe working practices and that refresher training where needed is arranged. The registered manager must ensure that all staff (including support workers) attend training specific to the needs of residents including mental health awareness and if needed managing challenging behaviour. The registered manager must ensure that an effective quality assurance and quality monitoring system, based on seeking the views of residents, is in place to measure success DS0000024885.V311417.R01.S.doc 30/11/06 30/11/06 30/11/06 31/01/07 28/02/07 31/01/07 13 YA39 24 31/12/06 The Royd Version 5.2 Page 26 14 YA42 13(4) 23(4)(a) in achieving the aims, objectives and statement of purpose of the home, this must include a report at appropriate intervals. The registered manager must ensure that a copy of the landlords’ gas safety certificate is sent to the Commission. 30/11/06 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 YA24 YA37 Good Practice Recommendations It is a recommendation that the Registered Managers office or place of work be easily accessible to residents, relatives and other persons such as healthcare professionals and not be out of sight on the second floor of House 23 – 25. The Royd DS0000024885.V311417.R01.S.doc Version 5.2 Page 27 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. 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