Inspection on 30/01/08 for 262 Tunnel Lane

This inspection was carried out on 30th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

262 Tunnel Lane 16/06/06

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 Gerard Hammond Unannounced Inspection 30th January 2008 09:00 Tunnel Lane, 262 DS0000016797.V359701.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 Tunnel Lane, 262 DS0000016797.V359701.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. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tunnel Lane, 262 Address Kings Heath Birmingham West Midlands B14 6JX 0121 443 4131 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) Friendship Care and Housing Association Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 16th June 2006 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. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Information was gathered from a range of sources to inform the judgements made in this report. An Annual Quality Assurance Assessment was completed and notifications received from the home considered. A visit was made to the home and the Inspector was able to meet with all of the residents during the course of the day. Conversations with some of them were limited due to their complex needs. The Manager and members of the staff team were spoken to. Time was also spent examining records (including personal files, care plans, previous inspection reports, staff files, and safety records) and completing a tour of the building. Thanks are due to the residents, Manager and staff team for their help and cooperation throughout the inspection process. What the service does well: Information is available to help people make their minds up about whether or not the service is right for them. People’s support needs are assessed properly, to make sure that they can get the support they need. Care plans have lots of good information in them, to help staff make sure that they support the residents in ways that they like. People are able to go out to places they like and to do things that they value. They are supported to keep in touch with the people who are important to them. Staff encourage them to do as much for themselves as they can, so that they can be as independent as possible. Residents get well looked after and are supported to get the help they need to stay healthy and well. They know that if they are unhappy, that their concerns will be listened to and taken seriously. The support they get helps to keep them safe from harm. Staff work hard to make sure that residents enjoy the benefit of living in a house that is comfortable, safe and homely. The Manager and staff are very positive about making the service better for the people who use it. Important checks on equipment and things around the home get done regularly, to make sure that the people living and working there can stay safe. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: In thinking about this, it’s important to recognise that the Manager has not yet had a lot of time to deal with all the things that need to be done to improve this service. There is good evidence that in the time she has been in her job improvements have been made and that things are continuing to get better. Care plans could be better if they were more “person-centred” and that it were possible to see clearly whether or not they had achieved their personal goals. All of the important information in people’s risk assessments needs to be put into their care plans, to make sure they can be supported properly to stay safe. There are still some maintenance and repair jobs that need doing around the house, to make sure that the place stays properly maintained and looked after for the comfort of the residents. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 7 Some training for staff has still not been provided. It is important that they are given this to make sure they have the knowledge and skills to support residents and meet their needs. Some staff have not received supervision as often as they should. There have been some improvements to this, and this needs to continue so that staff get the support they need to do their jobs well. Now that there is a Manager in post, it is important that she applies to be properly registered. A system making sure that people are happy with the quality of the service they receive needs to be put into place. It should be possible to see clearly how their views guide the way in which the service is developed. 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. Tunnel Lane, 262 DS0000016797.V359701.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 Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to help prospective residents make decisions about whether or not this service could meet their needs. Their strengths and support needs are properly assessed, to make sure they can get the care they need. People have a written contract, so that everyone is clear about his or her rights and responsibilities. EVIDENCE: At the time of the last key inspection, a requirement was made that the home’s Statement of Purpose and Service Users’ Guide should be updated. This has now been done. Sampling of residents’ personal files showed that current assessments of support needs are in place, and that these are being kept under regular review. The written response to the Annual Quality Assurance Assessment showed that contracts are now in place, as required at the last inspection: sampling of residents’ files confirmed this. Tunnel Lane, 262 DS0000016797.V359701.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s care support they decisions, so supported to grow. plans reflect their needs and wishes, so that they can get the need in ways they like. They are helped to make choices and that they can have more control over their lives. They are take risks responsibly, to give them opportunities to learn and EVIDENCE: Two residents’ personal files were sampled. Support plans were indexed, helping to find information more easily. Plans give detailed guidance to staff about people’s individual routines. The people who live in this house have highlevel complex support needs. A good knowledge of the significance of their routines and an understanding about their preferences and what works for them (or not) is of particularly important. Plans are kept under review through regular meetings with residents and by their key workers, who are responsible Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 11 for completing a monthly update / progress report. It is recommended that plans are developed to include individuals’ goals, which should have outcomes that can be clearly measured. It should be possible to tell whether or not targets set have been achieved. Goals should be evaluated when plans are reviewed: in this way people can see what is working and what might need to be changed. It is suggested that giving some thought to this when monthly meetings / updates are being done would help to keep goals “live” and monitor progress more effectively. Additional support for staff in the development of person-centred approaches would enhance this further. Direct observations of interactions between residents and staff provided evidence of support to make choices and decisions. One person is supported to try and help him manage his smoking habit. His cigarettes are kept for him but he becomes anxious about this: in order to empower him to have more control, staff are trying to achieve this by getting him to go to the local shop and buy them, so that he knows that he can have them each day. Others were seen being offered choices about going out, and what they wanted to eat and drink. Risk assessments were on file showing that potential hazards to residents had been identified, and control measures put in place to minimise the likelihood of occurrence. However, it was noted that, in some cases, not all of the information contained in the control measures had been transferred into the care plan. For example, the risk assessment for one man about going out into the community identified a number of items that he should have with him, but these were not shown in the corresponding daily routine / care plan. It is clear that proper consideration had been given to potential hazards and what to do to prevent them, but it is important that all essential information in this regard is included in people’s plans. Nonetheless, it should be acknowledged that risk assessments showed that the service has a positive attitude to the management of risk, seeing this as providing opportunities for residents to learn and develop, rather than as a way of preventing them from doing things. Tunnel Lane, 262 DS0000016797.V359701.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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People get support to go to places they like and do things they enjoy. They are helped to keep in touch with people who are important to them. They can make choices about what they want to eat, have a varied and balanced diet, and enjoy their food. EVIDENCE: Previous inspection reports have shown that residents are supported to pursue a range of valued activities, both at home and in the community, on a regular basis. Everyone has been away on holiday and staff organise days trips out as well. Records showed that residents go out shopping, use local cafes and restaurants, go to church, attend local clubs, go to the park and out for walks. One person’s file had an analysis of the activities that had been planned with him, showing the number of occasions each activity should take place within the given period, and how frequently this had actually occurred. This practice should be encouraged and developed. Activity opportunities should be clearly Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 13 linked to individuals’ assessed needs and agreed goals. Analysing what actually happens in this way can provide invaluable information about what has been achieved, what works for people and whether or not goals set are effective. Records also show that people are supported to keep in touch with their families, both through visits and contact on the telephone. Involvement of family members and also independent advocates is encouraged. Menu plans and records of meals eaten were examined, and provided evidence that residents have access to a diet that offers balance, variety and nutrition. They are actively involved in shopping for groceries and choosing what is bought. The small size of the home means that people’s individual choices can be easily supported, and alternatives are always available if required. Tunnel Lane, 262 DS0000016797.V359701.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are well looked after so that they get the support they need in ways that they like. Staff support residents to keep important appointments and to get their medicine in the correct amounts and at the right times, so as to help them stay healthy and well. EVIDENCE: As reported above, individual care plans provide staff with good guidance about how to support people according to their assessed needs and in ways that suit them personally. Conversations with staff show that they are sensitive to what works for different residents and understand potential triggers for anxiety and consequent challenging behaviour. The complexity of this task should not be underestimated, and the current staff team is working hard to build up further their knowledge and experience of these residents, so as to support them to the best of their ability. Direct observations of interactions between residents and staff showed that both were comfortable in each other’s company. Support was given with respect, warmth and Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 15 friendliness. People’s appearances provided further evidence that they had been appropriately supported with their personal care. Sampling of personal files showed that Health Action Plans are in place: these are specifically designed to ensure that people get the help they need to stay healthy and well, taking into account their individual assessed needs. As with comments made about general care planning, it is recommended that plans are developed to include goals that can be clearly measured. Files contained charts showing that people’s weight has been monitored regularly. Residents had been supported to keep appointments with the GP, Consultant Psychiatrist, Community Nurse, Dentist, Optician, and Chiropodist. One person has an individual diet plan devised with support from the Dietician. Referrals have been made to the Psychologist and Community Nurse to provide support for staff in the management of difficult or challenging behaviour. Two of the residents have epilepsy requiring the prescription of “rescue medication”. The Specialist Epilepsy Nurse also monitors the care of both of these residents regularly. Epilepsy management plans are in place and filed with the Medication Administration Record (MAR). One of these residents has been particularly prone to seizures during the night, so a specialist alarm has been purchased to improve monitoring. Previous reports have identified particular problems with regard to accuracy of recording of medication given to residents, though this has improved more recently. The Medication Administration Record was examined and had been completed appropriately. Protocols were in place for PRN (“as required”) medication, and there are appropriate arrangements in place for the separate storage of the above-mentioned “rescue medication”, as a Controlled Drug, with supporting records as necessary. The medication store was clean and tidy, and secure. Tunnel Lane, 262 DS0000016797.V359701.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns are listened to and taken seriously. They are protected from abuse, neglect and self-harm. EVIDENCE: Appropriate complaints policy and procedures are in place and these are also available in alternative formats so as to make them more accessible for people with communication support needs. The levels of learning disability of most of the people living in this house mean that formal processes may have limited relevance. Residents are dependant on the vigilance of members of the staff team to notice changes in demeanour, behaviour or “body language” as indicators that something might be amiss. However, it should be acknowledged that the organisation is very proactive in this area and seeking to develop the ways in which people have an opportunity to let it know about things that concern them. This includes an existing complaint card system whereby each person has a stamped addressed card that can be sent directly to a senior manager by a resident or representative. Receipt of these cards prompts a visit by someone outside the home to follow up the concern. A Tenants’ Forum, providing opportunities for residents to meet with people who live in other homes run by the organisation has also been started. Previous reports show that each individual has his own bank account and that personal money is paid directly into this. Records show that that staff support residents to go to the bank regularly to get their money. Care plans are backed Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 17 by individual risk assessments to minimise the hazard of financial abuse and detailed records maintained including receipts. It was noted that one resident has a trust fund, and the family solicitor administers that this. Staff records show that all members of the care team have received training in the protection of vulnerable adults from abuse. Staff files also contain evidence of appropriate checks being made with the Criminal Records Bureau before employment. Local Multi-Agency Guidelines for safeguarding adults are in place. An adult protection matter brought to the attention of the Acting Manager was reported and subsequently investigated appropriately in accordance with organisational policy and procedure and local guidelines. Tunnel Lane, 262 DS0000016797.V359701.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, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the benefit of living in a house that is comfortable and homely and meets their needs. EVIDENCE: A number of concerns were raised at the time of the last key inspection about jobs that needed to be done around the house in order to improve the quality of the home environment. At a subsequent random inspection it was noted that the requirements made previously had all been met. New sofas and carpets were bought for the lounge. Staff have made particular efforts to make this room comfortable and homely, with the inclusion of pictures and photographs on the wall. A new dining table is now needed and staff advised that a requisition has been made for this. The kitchen has been completely refitted. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 19 Residents’ bedrooms were all individual in style, generally well decorated and with personal possessions and effects in evidence. It was noted that the wallpaper in one person’s room (MH) was in need of repair. On the upstairs landing some plasterwork around the door at the top of the stairs is in need of repair. The windowsill at the other end of the landing needs repainting. In the bathroom it was noted that the bath panel was in need of painting / replacement, and the seal around the bath in need of repair. A number of the radiator covers were in need of attention as the ends were coming off. However, the Acting Manager was able to produce the schedule for reporting maintenance and repair jobs. She said that matters were usually dealt with quickly and the record provided evidence that this was generally true. A number of repairs were carried out on the day of the inspection visit. It has to be acknowledged that the support needs of this particular group of residents means that wear and tear on fixtures and fittings around the house is certainly above average. As reported above, staff work hard to make the place comfortable and welcoming, so that residents can enjoy their home. The house was clean and tidy, with good standards of hygiene maintained throughout. The home is “an ordinary house in an ordinary street” and blends in with all the other houses in the neighbourhood. To the side and rear of the property is a large garden, which staff say gets a lot of use when weather conditions permit. One resident has his own shed. Previous reports show that some residents are supported to grow things in the garden and tend pots and plants. Tunnel Lane, 262 DS0000016797.V359701.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): 32,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of staff training need to be improved, to ensure that they have the knowledge and skills they need to support residents properly. Checks are carried out to make sure that people working in the home are fit for the job. Supervision of some staff needs to be more often, to make sure that residents are cared for by well-supported workers. There are, however, signs that this is improving. EVIDENCE: The staffing complement meets minimum staffing levels. Vacancies and absences are covered by the existing team and a small regular team of reserve staff. This provides continuity of care for the residents, which is of particular significance for this group of people. The care team includes a component whose specific areas of responsibility are supporting residents in their day activity programmes. The whole staff group has meetings together, to share information and keep updated on issues relating to residents’ care. These generally take place each month, but the Manager reported that there had been problems with arranging these recently. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 21 At the time of the last inspection a number of shortfalls were identified in staff training and requirements subsequently made. Most of these have been met: staff have done training in fire safety, adult protection, and food hygiene. Most have done manual handling training, but it was noted from available evidence that some of these are now in need of a “refresher”. Similarly, available evidence showed that four of the current staff team have had training in supporting people with Autistic Spectrum Disorders, and one in Mental Health. Training should also be provided to bring staff up to date with the implications of the Mental Capacity Act 2005, which has come into effect since the last inspection. Action should be taken to ensure that staff receive all the training they need, appropriate to the work they do and taking account of the full range of support needs of the people in their care. It was recommended that the staff training and development plan be developed and presented in a spreadsheet format showing (for each member of staff) training completed and qualifications gained, with relevant dates. The plan should highlight gaps (including refreshers) and show when outstanding training is to be delivered. Training within the organisation is generally organised centrally. Presenting information in the way suggested should provide the Manager with a clear overview of staff needs and a useful tool with which to plan and “bid” for required training. New staff go through a structured programme of induction over their first 6 months. A new member of the day support team was observed completing tasks from her induction workbook. The home’s Annual Quality Assurance Assessment (AQAA) shows that 50 of staff hold qualifications at NVQ level 2 or above. Staff files were sampled: some would benefit from a general tidy up. It is suggested that these are indexed and divided, for example, into sections relating to recruitment, training, supervision, leave, and so on, and that the system adopted is universally applied. All of the files sampled had completed application forms and evidence of checks with the Criminal Records Bureau (CRB). All but one (AC) contained copies of two written references, as required. All of the files sampled showed that staff had received an annual appraisal (PDR – performance and development review) but evidence of regular formal supervision was more variable. There is however clear evidence that this is now improving. It has to be acknowledged that this home has been without a Registered Manager for a significant amount of time. The current Manager was confirmed in post in September 2007 and has therefore not yet had a great deal of time in which to address outstanding matters. Clearly, some issues have had to be allocated first priority, but there is plenty of evidence to suggest that, given time, any identified shortfalls will be sorted out appropriately. Staff present themselves positively and clearly have the best interests of the people in their care at heart. Tunnel Lane, 262 DS0000016797.V359701.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 &42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The conduct and management of the home have been improved since the appointment of a Manager, and there are positive signs that the service will now improve further, for the benefit of the people using it. A proper system needs to be put in place to show how residents’ views underpin the development of the service. Important checks are generally carried out around the home to ensure the safety of the people living and working there. EVIDENCE: As reported above, the current Manager was confirmed in post in September 2007. She currently holds qualifications at NVQ level 3, but has commenced working towards gaining level 4 qualification with the intention of progressing to the Registered Manager’s Award in due course. She has previous experience Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 23 of “acting up” as a home manager in other services run by the organisation. She presents positively and is working hard to build up the care team and develop the service for the benefit of the people who use it. She said that she feels well supported by her line manager. An application to register the Manager with the Commission for Social Care Inspection should now be made. As reported above, she has not yet been in post long enough to address all of the matters that require her attention, and this should not be understated. However, there are positive signs that steady improvements are being made and that outstanding issues will be dealt with in time. A system for monitoring and assuring the quality of the service provided needs to be put in place and implemented fully. The Manager reported that visits on behalf of the Registered Provider take place each month as required. Other related activity has been referred to earlier in this report, including key worker meetings, care plan reviews, analysis of activity opportunities, tenants’ forum and so on. The organisation has a generally good record in taking positive action to find out what people think about the services provided. Work already done in this regard needs to be collated, information analysed, and findings made available, so that these show how the views of people using the service have been used to guide its future development. The additional development of person-centred planning and setting goals with measurable outcomes could support this process further. Safety records were sample checked. Each month a health and safety audit and maintenance report is submitted to senior managers. Efforts are made to involve residents in these where possible to promote their independence and enhance their sense of ownership. The workplace risk assessment has been reviewed: this responsibility is to be transferred to an external team within the organisation in the future. Records of checks on the fridge and freezer and water temperatures have been completed appropriately. Food stored in the fridge was labelled appropriately. Checks on the fire alarm have generally been done, though there was a three-week gap during the summer last year. The alarm and emergency lighting systems, and the fire-fighting equipment have been serviced. A fire evacuation drill is due shortly. Tunnel Lane, 262 DS0000016797.V359701.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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 3 X Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 (1 a &c) Requirement You must ensure that staff receive the training they need so that they have the skills required to support people according to their assessed needs. You must ensure that staff are supervised sufficiently regularly to ensure that they have the support they need to do their jobs properly. You must forward a completed application to register the Manager with CSCI (Outstanding since 31/01/07) Timescale for action 30/04/08 2. YA36 18 (2) 30/04/08 3. YA37 7, 8, 9 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Develop the use of person-centred approaches in individuals’ care plans, and set goals with outcomes that can be measured. Doing this will help to show whether or not people are achieving their personal goals. Make sure that information in risk assessment control DS0000016797.V359701.R01.S.doc Version 5.2 Page 26 2. YA9 Tunnel Lane, 262 3. YA39 measures is fully transferred into people’s care plans, so as to minimise risk of harm. Fully implement a system for monitoring and quality assurance, so that it can be seen that the views of people using the service underpin its review and development. Tunnel Lane, 262 DS0000016797.V359701.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tunnel Lane, 262 DS0000016797.V359701.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!