Inspection on 16/06/06 for 262 Tunnel Lane

This inspection was carried out on 16th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

262 Tunnel Lane 30/01/08

262 Tunnel Lane 01/11/05

262 Tunnel Lane 20/06/05

262 Tunnel Lane 02/12/04

262 Tunnel Lane 30/04/04

262 Tunnel Lane 17/12/03

262 Tunnel Lane 16/09/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Tunnel Lane, 262 Kings Heath Birmingham West Midlands B14 6JX Lead Inspector Sarah Bennett Unannounced Inspection 16th June 2006 10:00 Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tunnel Lane, 262 Address Kings Heath Birmingham West Midlands B14 6JX 0121 443 4131 F/P 0121 443 4131 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) FCH Housing & Care Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 1st November 2005 Brief Description of the Service: 262 Tunnel Lane is located in Kings Heath, Birmingham. The home is set within an established residential area. It is not recognisable as a care home, but blends in with ordinary domestic houses. The home briefly comprises of the following, on the ground floor there is a kitchen, open plan dining room and lounge, a bathroom with walk in shower, a toilet and laundry room. There is one bedroom on the ground floor; the other four bedrooms are located on the first floor. There are two additional bathrooms with WCs. The staff sleep -in room is a combined office. To the rear of the home there is a large garden, which has ramped access and raised flowerbeds. The home has a combined lounge and dining room. There is no space for tenants to meet in private, other than tenant’s own bedrooms. There is no alternative room for tenants who smoke. An extractor fan is provided in the dining room, which is used by tenants who smoke. However, tenants are encouraged to smoke in the garden when possible. The current scale of charges as stated in the pre-inspection questionnaire is £1102.52. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a completed pre – inspection questionnaire. One inspector carried out the unannounced fieldwork visit over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. The staff on duty and the Business Manager was spoken to. Conversations with some tenants were limited due to their complex needs. The inspector met with four of the tenants and time was spent observing care practices, interactions and support from staff. One of the tenants has been in hospital since last August. Staff support them each day by visits and an alternative long-term placement is being sought. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? A lot of things had improved since the last inspection. Care plans and risk assessments had been updated and were detailed so that staff know how to support individual tenants to meet their needs and achieve their goals. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 6 Recording of health improvements was better to ensure that the right action is taken so that individual’s health needs are met. New curtains had been fitted in the lounge, dining room and one of the bedrooms. A new carpet and sofas for the lounge had been ordered, which will make it a more comfortable place to live in. The recording of the controlled medication kept for individual tenants had improved. It was being checked regularly ensuring that it was being stored safely and not used inappropriately. Staff were testing the fire equipment regularly to make sure it was working. 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. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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): 1, 2, 4, 5 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective tenants do not have the information they need to make an informed choice about where to live. Prospective tenants individual aspirations and needs are assessed before they move into the home. They have an opportunity to visit the home before they move in. Tenants do not have individual contracts so are not aware of the terms and conditions of their stay at the home. EVIDENCE: The service users guide was updated in October 2005. It included all the relevant and required information. It was produced using pictures however there were many pictures and words, which could make it confusing and difficult to understand. The statement of purpose was not dated. It included the details of the previous registered manager. Some parts of it had not been completed and some parts were not relevant to Tunnel Lane. The service users guide included the assessment process and stated that there must be a care plan and risk assessments completed before the person moves in. It also said that the person would visit the home for a drink, meal and overnight stay before moving in to see if they would like to live there. This process is not reflected in the admission policy that was produced several years and does not include all the information required to meet this standard. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 9 The contracts were not available. The Business Manager said that they are getting the individual three – way placement agreements in place. Until this is done they do not want to produce a contract that may give the tenants the wrong information and lead to confusion. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The 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 in care plans to ensure they support individual tenants to meet their needs and achieve their goals. Tenants are supported to make decisions about their day-to-day lives. Tenants are well supported to take risks within a risk assessment framework. EVIDENCE: Two tenants records were sampled. These included an individual care plan. Care plans had been improved since the last inspection. They were detailed and stated how staff are to support the individual with their personal hygiene, eating, doing household tasks, travelling, communication needs, mobility, social, relationships, finances and their health needs. Care plans included step – by - step details of the support that the individual needed so that they can be supported consistently by all staff. Some photographs were included of the individual for example making their breakfast so staff could be clear as to the support required. One of the tenants behavioural support requirements had not been completed. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 11 Staff said that tenants meetings are not held, as tenants do not participate in the setting of a formal meeting. Staff said that tenants do make decisions and are consulted on what they want to do and where they want to go each day. This was observed throughout the day. Care plans sampled showed that staff had sought the views of tenants in developing them. One of the tenants attends the monthly FCH tenants forum. They are also involved in visiting other homes managed by FCH as part of the quality audits. The Business Manager said they hope to develop the participation of the tenants within FCH and hope to get more tenants involved in doing quality audits. Each tenant had individual risk assessments. These contained sufficient detail to enable staff to ensure that the risks to tenants are minimised when bathing, at night, if there was a fire, smoking, when outside in the sun, their behaviour, finances, health needs, mobility and using the kitchen. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home experience a meaningful lifestyle and are offered a healthy and varied diet. EVIDENCE: Tenants take part in the City College programme. Through this they develop their skills in doing their laundry, personal hygiene, cooking, cleaning and gardening. Many of the activities are done in-house and tenants have to provide evidence using photographs and evidence from staff that they have completed the programme and gained the skills. Records of the progress that individuals make are completed with details of the skills to maintain and the skills to work towards. Staff said and tenants records sampled showed that tenants have been on day trips recently to Warwick, Cheddar Gorge, the car and transport museum in Coventry, Dudley Zoo, Malvern, Worcester, Evesham and Ross –on – Wye. Records sampled showed that tenants regularly go shopping, to restaurants and cafes, parks, for picnics, walks and to museums. A vehicle is provided for Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 13 tenants to access the community. They also are supported to use public transport. During the day one tenant went out with staff on public transport to Sutton Coldfield, one tenant went to the park and the pub for lunch and another tenant went strawberry picking. One tenant chose to stay at home and was supported to do household tasks and prepare for a weekend visit to their family. Inside the home tenants do puzzles, watch TV, listen to music, do their laundry and ironing and read newspapers and magazines. Staff were observed supporting tenants to put away their laundry and clean their bedrooms. Records sampled showed and staff said that tenants are supported to maintain contact with their family and friends through visits to them and inviting them to visit, by telephone and through buying cards and gifts for special occasions. Staff also support tenants who want to to visit the tenant who is in hospital. All tenants have planned or are planning holidays, one tenant is going to Ireland, two are going to South Wales and another is planning to go on holiday in October but has not yet decided where to. Records of meals provided showed that a variety of food is offered. Where appropriate low fat diets are catered for and these include reducing portion sizes. Food provided and menus are appropriate to and reflect the cultural background of the individuals who live in the home. Adequate food stocks were available and these included fresh fruit and vegetables. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants receive personal support in the way they prefer and require and their health needs are met. The arrangements for the management of the medication within the home protect the tenants. The illness of a tenant had been handled with respect, as had the death of another tenants relative. EVIDENCE: Individual care plans detailed the support that staff needed to give to tenants in relation to their personal hygiene. One care plan stated that the person likes to wear hair gel and then detailed what support staff should give to apply it. Staff spoke about how they support individuals to manage their anxiety particularly when accessing the community. They said it is necessary to plan where they are going and through getting to know the individual have found that when going to one shopping centre the person is less anxious if they park the car in the same road. This ensures that the tenant enjoys the visit and is at less risk when crossing the road. Each tenant had an individual Health Action Plan. This is a personal plan about what support a person needs to stay healthy and access the relevant Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 15 healthcare services. This cross-referenced to the health needs identified in their individual care plan. Records sampled showed that tenants weight is checked monthly and that this is generally stable. Losing or gaining weight can often be an indicator of health problems therefore it is good that tenants weight is regularly checked. Two tenants are prescribed Epistatus ‘rescue’ medication to use in the event of an epileptic seizure. They each had individual protocols on how staff should administer this. The Psychiatrist and the Epilepsy Nurse developed these. Staff had received training in how this should be administered and stored. It is stored as a Controlled Drug (CD) in a separate cabinet and is checked and recorded in the CD book by two staff at each handover. The CD book crossreferenced with the amount stored in the cabinet for one tenant. During the afternoon one tenant had an epileptic seizure while out in Worcester with a member of staff. Staff administered ‘rescue’ medication and ensured that the tenant was taken to the local A& E Department. The senior staff back at the home ensured that another prescription of the ‘rescue’ medication was ordered and arranged for another member of staff to go to the hospital to be with the tenant. This was well managed to ensure the safety and well being of the individual. Medication Administration Records (MAR) were seen for two tenants and had been signed for appropriately. Individual protocols for PRN (as required) medication were in place and were detailed as to when, why and what dosage the medication should be given. Records sampled showed that tenants medication is regularly reviewed. One of the tenants has been in hospital since last August following a stroke. Staff have supported the individual at the hospital each day and where appropriate have supported other tenants to visit them. They have also supported their relative to visit them regularly in hospital. Due to the changing needs of the individual it is not possible for them to return home but the Business Manager said that staff would continue to support the tenant until an alternative placement had been found. Staff said that one of the tenant’s relatives had recently died and they had supported the tenant to visit them at the final stages of their life. They also supported them to frame a photograph of the tenant with their relative and keep it safely so that it would not be damaged if their behaviour became ‘challenging’. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints are adequate to ensure that tenants views are listened to and acted on. Arrangements are not yet sufficient to ensure that tenants are protected from abuse. EVIDENCE: Tenants records sampled included a copy of the complaints procedure. This was produced in large print and stated that it was also available on a CD so making it more accessible to the tenants. It included all the relevant and required information including details of how to contact the CSCI to make a complaint. In each tenants bedroom there are complaint cards with a stamped addressed envelope to enable the tenant or their visitors to make a complaint if they wish to. The pre-inspection questionnaire stated that in the last 12 months there had been one complaint made that had been substantiated. Details of this complaint were seen. It was investigated appropriately to ensure that the issues raised were resolved and steps to ensure that improvements were made were taken. Each tenant has their own bank account. Records sampled showed that staff support tenants to go to the bank regularly to get money out. Individual financial records cross-referenced with the amount in their individual wallet. Bank statements showed that tenants benefits are regularly paid into their accounts and they regularly receive their personal allowance. Each tenant has a financial risk assessment that states how the risks of them being financially abused are minimised. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 17 Tenants records included behaviour management strategies stating how staff are to manage their behaviour so it is managed in a consistent way. Training records showed that ten out of fourteen members of staff had received training in Managing Challenging Behaviour. Training records showed that seven members of staff had received training in adult protection and the prevention of abuse. The Business Manager said that all staff would complete this training by the end of November 2006. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The condition of the decoration and furnishings had improved but further improvement is needed to ensure that tenants live in a homely and comfortable environment. EVIDENCE: The environment has improved since the last inspection. New curtains had been provided in the lounge and dining room. New sofas and carpet had been ordered for the lounge. The lounge was well decorated and had several pictures and photographs on the walls making it look homely. New curtains had been provided in the ground floor bedroom and tiles had been fitted on the walls around the sink to prevent splashes of water from spoiling the decoration. The bedroom was personalised and staff were supporting the tenant to clean and tidy it. Staff and tenants said that the tenants had been involved in choosing the new furniture and decoration. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 19 Staff said that quotes had been obtained for redecoration of the upstairs bedrooms, bathrooms and the ground floor WC and shower room. The kitchen was in need of refurbishment as required at the last inspection. Staff said that quotes for this are being obtained and this work should be completed during this summer. In the WC and bathrooms hand towels and hand wash were provided to help minimise the risk of cross infection. In the ground floor WC the lid on the bin was broken so increasing the risk of cross infection. Staff said that this had recently been replaced but another would be bought. The home was clean and free from offensive odours. The garden was well maintained. Tenants who are interested are involved in the garden and one tenant is growing tomatoes and strawberries. There were attractive hanging baskets and pots and garden furniture is provided. A goal post was provided on the grass and staff said that other outdoor games had been bought and they are hoping that tenants would be able to use the garden more. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 36 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate so that tenants are supported appropriately. Tenants are protected by the home’s recruitment practices and staff are well supported. Arrangements for developing staff are insufficient and could affect their ability to meet individual’s needs. EVIDENCE: The pre-inspection questionnaire said that one member of staff had left since the last inspection. The Business Manager said that this vacancy had been recruited to. Staff are divided into two teams – residential and day opportunities that gives tenants an opportunity to take part in appropriate activities during the day. However, all staff meet together regularly and minutes of staff meetings showed detailed discussion of individual tenants needs. Currently two staff supports one of the tenants from 10am – 9pm to ensure their needs are met. This takes the service above their staffing complement but the Business Manager said that they hope to secure funding for this individual in the near future. Rotas showed that minimum staffing levels are met. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 21 Three staff records were sampled. These included the required recruitment records including evidence that a Criminal Records Bureau (CRB) check had been undertaken to ensure that suitable people are employed. Staff training records showed that staff had received training in fire safety, first aid and the care of medicines. Seven out of fourteen members of staff had received training in adult protection and the prevention of abuse. The Business Manager said that all staff would complete this training by the end of November 2006. Ten staff had received training in Managing Challenging Behaviour. Six staff had received manual handling training and eight had received training in food hygiene. The preparation of food and supporting tenants to prepare food is a part of each member of staff’s role. Four staff had received training in autism and two in mental health. Given the needs of the tenants all staff must receive this training to ensure they have the skills and knowledge to meet their needs. Staff records sampled showed that staff had regular, formal recorded supervision sessions. These identified individual training and development needs and staff discussed with their manager their role and the needs of the tenants. Records showed that staff had not had an annual performance development review. The Business Manager said that they were aware of this and this would be a priority when the new manager is in post. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The absence of a Registered Manager has not ensured that tenants have always benefited from a well run home. A quality assurance system is not in place so tenants cannot be confident that their views underpin all self-monitoring, review and development by the home. Adequate arrangements are not in place to ensure that the health, safety and welfare of tenants is always promoted and protected. EVIDENCE: The home has been without a Registered Manager since before the last inspection. One of the Assistant Team Leaders has been Acting Manager with the support of the other Assistant Team Leader and a Registered Manager from another home managed by FCH. Since the last inspection some improvements had been made in record keeping and the day-to-day running of the home. However, this arrangement is not suitable on a long-term basis. The Business Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 23 Manager said that a new manager had been recruited who would be starting soon. The Business Manager said that a quality assurance system is not in place. They plan to involve the FCH tenants forum in developing this to ensure that the system reflects the views of the tenants and looks at the things that are important to them. Fire records showed that staff regularly tests the fire equipment to make sure it is working. Staff said that they hope to involve one of the tenants in doing these tests. A copy of details of how to do the fire and health and safety tests in a picture format that the person would be able to understand was seen. A fire risk assessment was completed that showed how the risks of a fire starting are to be minimised. In the fridge there was a bowl of food but this was not labelled with what it was or when it had been made or needed to be eaten by. There was a packet of luncheon meat that stated that it should be used by 15th June 2006 so was out of date. All food must be labelled and dated and out of date food thrown away to prevent the risk of food poisoning. New chopping boards had been purchased as recommended by the Environmental Health Officer when they visited in May 2006. Staff test the fridge and freezer temperatures daily and these were within the limits for safe food storage. The pre-inspection questionnaire stated that an electrician completed the five yearly electrical wiring testing in 2003 and stated that it was in a satisfactory condition. Training in food hygiene and manual handling has not been provided for all staff and this is required. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records of these showed that in June they ranged from 26 – 40 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. The Business Manager said this had been identified and a new pump is needed on the boiler, which would be fitted in the next couple of weeks. Risk assessments are in place for the premises, staff and manual handling. These identified the key risks but were not that detailed. The action plan to reduce the risks did not state the target date by which the action should be taken. Detailed assessments were in place for all hazardous substances used to ensure these are used safely. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 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 Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 25 CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 3 5 2 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 2 25 x 26 2 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 x 1 x x 2 x Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 (1) (ac) (2) 5 (1) Requirement The statement of purpose must be updated to include all the information required under Schedule 1. Each tenant must have a copy of the contract that includes all the required information. Outstanding from previous inspections. All needs identified in tenants care plans must be completed. The kitchen units must be replaced. Outstanding from the last inspection. Tenants bedrooms must be redecorated. Outstanding from the last inspection. The bathroom and toilets must be redecorated. Outstanding from the last inspection. All staff must receive training in adult protection. Outstanding from previous inspections. Timescale for action 30/09/06 2. YA5 30/09/06 3. 4. YA6 YA24 15 (1) 23 (2) (b, c) 23 (2) (b, d) 23 (2) (b, d) 13(6) 18 (1) (a c) 31/07/06 30/09/06 5. YA26 31/10/06 6. YA27 30/11/06 7. YA23YA35 30/11/06 Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 27 8. YA35YA42 18 (1) (a, c) 18 (1) (a, c) 13 (4) 18 (1) (a, c) 7, 8, 9 24 (1) (2) (3) 13 (4) (ac) 13 (4) (ac) 9. 10. 11. 12. YA35 YA35 YA37 YA39 13. 14. YA42 YA42 All staff must receive training in food hygiene. Outstanding from previous inspections. All staff must receive training in manual handling. All staff must receive training in A – Autism B - Mental Health An application for Registered Manager must be submitted to the CSCI. A quality assurance system that considers the views of tenants and their representatives must be in place. All food opened or cooked must be labelled and dated. All out of date food must be thrown away. Risk assessments for the premises, staff and manual handling must be detailed and include target dates by which action should be taken to minimise risks. 30/11/06 30/11/06 31/12/06 30/11/06 31/12/06 16/06/06 31/08/06 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. 2. 3. Refer to Standard YA1 YA2 YA36 Good Practice Recommendations The service users guide should be revised so it is in an accessible format and easy to understand. The admission policy should be updated. Each member of staff should have an annual performance development review. Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tunnel Lane, 262 DS0000016797.V290178.R01.S.doc Version 5.1 Page 29 - 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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