CARE HOME ADULTS 18-65
Walsall Road, 804 Great Barr Birmingham West Midlands B42 1EU Lead Inspector
Gerard Hammond Unannounced Inspection 14th February & 2nd March 2006 11:10 Walsall Road, 804 DS0000016937.V284203.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 Walsall Road, 804 DS0000016937.V284203.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. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Walsall Road, 804 Address Great Barr Birmingham West Midlands B42 1EU 0121 358 0412 0121 358 0412 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) londonroad@tiscali.co.uk Milbury Care Services Limited Mrs Lisa Hannah Carey Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Walsall Road, 804 DS0000016937.V284203.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 September 2005 Brief Description of the Service: 804 Walsall Rd is registered to provide accommodation, care and support for three people with learning disabilities. The property is a detached bungalow, located on the main Birmingham to Walsall road in the Great Barr area of Birmingham. The Scott Arms Shopping Centre is within walking distance, and the home is well situated for local amenities including public transport and local shops. The accommodation includes a through lounge and dining area, a domestic scale kitchen, and separate laundry. The bathroom offers assisted bathing facilities, and there is a separate toilet available also. One of the three bedrooms has en-suite facilities. There is also a small office. To the rear of the property is an attractive private garden, which is accessible for wheelchair users via a ramp. The home is comfortably furnished and well maintained. There is off-road parking for several vehicles on the drive at the front of the house. The Registered Manager also has responsibility for another small home situated about a hundred yards further along the road. Both houses are run by Milbury Care Services. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over two visits and was unannounced. This report should be read in conjunction with the one written following the previous inspection completed on 30 September 2005. Direct observation and sampling of records (including personal files, care plans, safety records and previous inspection reports) were undertaken for the purpose of compiling this report. The Inspector met all of the residents, but, as previously indicated, their communication support needs and level of learning disability make it difficult to seek their views directly. Over the two visits, the Inspector formally interviewed the Manager and Deputy Manager and spoke with two other staff members informally. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
Continued efforts have been made to meet requirements and work towards National Minimum Standards. Work has continued on care plan development, and there is clear evidence that efforts have been made to begin setting goals, as required. Care plans and risk assessments are now generally indexed and crossreferenced, and organisation of records is improving. The Home’s Statement of Purpose has been updated to more accurately reflect the current position. Some positive action has been taken to seek support and develop activity opportunities for one resident with complex care needs. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 6 One of the residents is having substantial refurbishment work done in his bedroom. 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. Walsall Road, 804 DS0000016937.V284203.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 Walsall Road, 804 DS0000016937.V284203.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 Appropriate information is available to assist prospective residents in making a choice about this service, but an application must be made to vary the current Conditions of Registration. EVIDENCE: Key Standard 2, and Standards 1 and 4 were assessed at the time of the last inspection. A requirement to update the Statement of Purpose to reflect the age range of residents cared for in the home has now been met. As previously reported, an application to vary the conditions of registration must now also be made. There have been no further admissions since the last inspection. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 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): 6, 9 Care plans are being developed to include residents’ personal goals and to expand detailed information of how support is given. Good work already done needs to be continued. Responsible risk-taking is encouraged in order to support independence, but assessments need continuing development. EVIDENCE: Key Standards 6, 7 and 9 were all assessed at the last inspection. Standard 7 was met in full, and Standards 6 and 9 partially met. Sample checking of care plans provided evidence that good work has gone on since the last inspection, and that this remains a work in progress. Plans were well presented, appropriately indexed, and cross-referenced with risk assessments. Clear efforts have been made to set some goals. This work should be acknowledged, commended and built upon. Residents’ communication guidelines continue to be in need of development. Support has been sought from the Speech and Language Therapy service, and
Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 10 residents’ it is hoped that this input will help staff to take this task forward. Again, this initiative should be commended. Detailed guidance about how to provide support is being built into individuals’ care plans, and this needs to continue. Identifying people’s specific support needs should help in guiding staff towards setting goals appropriately. It is important that there is a clear focus on ensuring that the outcome for any goal that is set can be measured. In this way it should be possible to produce clear evidence of whether or not goals have been achieved, when the care plan is reviewed. Sampled risk assessments were cross-referenced to care plans, as previously required. It was noted that one resident needs a risk assessment for using public toilets when engaged in community-based activities. (It might also be useful to set a related goal that staff research the situation of facilities for people with disabilities in the local area.) However, risk assessments continue to require review and development, so that hazards are correctly identified and control measures incorporated into care plans appropriately, as reported at the time of the last inspection. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 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): 12, 13 Residents take part in some appropriate activities and access their local community, but opportunities remain limited. Planning and recording of activities need to improve. EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the last inspection. Standards 15, 16 and 17 were met in full and Standards 12 and 13 partially met. A requirement was made that the range, quality and frequency of activity opportunities for residents should be developed further. Since the last inspection, some assistance has been obtained from the Occupational Therapy and Speech and Language Therapy services to begin this work. There are particular concerns about the opportunities available to one resident, who has sensory impairment and complex support needs. It has been reported previously that action was being taken to provide more equipment and to develop the facilities in her room, so as to improve communication opportunities and sensory stimulation. Plans need to be translated into action:
Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 12 this now needs to be taken forward, and will be more fully assessed at the next inspection. Activity recording continues to be in need of development, as reported at the last inspection. Recording should indicate the purpose of activities, and there should be clear links between activities offered and people’s individual goals and care plans. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 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): 18, 19 Residents receive a good standard of personal support in relation to their general care needs. Physical and emotional health needs are also generally met, but some aspects continue to require attention. Specific Health Action Plans should now be put in place for each individual. EVIDENCE: Key Standards 18, 19 and 20 were all assessed at the last inspection. Residents’ attire and personal grooming provided evidence of a good standard of basic personal care. As previously reported, interactions between staff and residents were observed to be friendly, warm and respectful. A previous requirement to develop one resident’s epilepsy care plan has been met. However, sampling of another resident’s records revealed that, though she is currently taking medication to control epileptic seizures, no plan of care could be located on her personal file. There was a risk assessment, which referred to guidelines, but there was no indication of where these could be found either. A previous requirement to develop a protocol in respect of this person’s bowel care has now been met. It was also previously reported that some work had been done to begin the development of Health Action Plans, and this should now be taken forward and completed.
Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: Key Standards 22 and 23 were assessed at the last inspection. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 15 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): 28 Shared spaces complement residents’ own room, but are in need of some attention. EVIDENCE: Key Standards 24 and 30 were assessed and met in full at the time of the last inspection. As previously reported, 804 Walsall Road is an adapted domestic scale property, and is very homely in style. People’s bedrooms are individually styled, and there is ample evidence of personal possessions and effects throughout. It was noted that work had begun on refurbishing one resident’s bedroom. The house is kept clean and tidy, and a good standard of hygiene is maintained. Previous inspection reports have noted that communal areas are now showing signs of wear and tear and would benefit from redecoration. It was observed on this visit that the front door is in need of a fresh coat of paint or stain. It was also noted that the fridge in the kitchen is not working properly, and a requirement was made that this should be replaced. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 16 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): 34, 35, 36 General recruitment practice provides residents with appropriate protection, but some issues relating to records need to be addressed. A current staff training and development plan is required, and training relevant to residents’ assessed care needs should be provided. Arrangements for the formal supervision of some staff members need to improve. EVIDENCE: Key Standards 32 and 35, and Standards 33 and 36 were assessed at the last inspection. Standard 36 was fully met on that occasion, and Standards 32, 33 and 35 partially met. Three of the current staff team’s files were sample checked. None had a current photograph on file, as required. Two of these staff have been with the Organisation for several years and were transferred from employment with the then local Health Authority, so recruitment records are incomplete. The other person’s file contained relevant documentation. It is recommended that files be organised in such a way that records relating to recruitment (and required to be maintained under the Care Homes Regulations 2001) are collated in one section of the personal record, and that positive use is made of the checklist
Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 17 (already available within the Organisation) specifically designed for this purpose. Available information on training indicated significant gaps. Members of the current staff team need to be provided with training in supporting people with epilepsy and also autistic spectrum disorders, in accordance with residents’ assessed care needs. An up to date training and development plan for the staff team is also required. As previously indicated, this should show (for each member of staff) details of training undertaken and qualifications gained. It should also highlight any gaps (including refreshers) and show when outstanding training is scheduled, and who is to deliver it. It should be acknowledged that the Organisation operates a rolling programme of training for its staff throughout the region. Sampling of individuals’ supervision records revealed a variable picture: some were up to the required standard, but others were not and this must be addressed. (See Standard 37 also.) Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 18 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 Residents have benefited from living in a home that has generally been well run. The Organisation should produce a report demonstrating how residents’ views underpin service review and development. General practice promotes the health, safety and welfare of people living in the house, but some issues require attention. EVIDENCE: The Manager advised that she has recently completed work for the Registered Managers’ Award and is currently waiting for verification. The Registered Manager for this home also has managerial responsibility for another small home situated a few minutes walk away, on the same road. A letter has been received since the inspection visit advising that the Registered Manager is leaving her position shortly to take up a new post. The Registered Provider should advise CSCI of the arrangements now being made
Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 19 to manage the Home. This should include an indication of how it is proposed to allocate time between the two homes if the current arrangements are to continue, and if there are expectations that the Manager will be expected to spend any time “on rota”. Reports of visits required under Regulation 26 (Care Homes Regulations 2001) have been received periodically by CSCI. It should be noted that these visits should be carried out at least once a month, and that such visits should be unannounced. The Organisation should produce a report of its Quality Assurance and Monitoring activity, demonstrating how the views of people living in the house have been taken into account in the review and development of their service. Fire safety records were sample checked. It was noted that testing of the fire alarm system had been appropriately completed in general, but there are still gaps in recording. This was identified at the time of the last inspection, and must now be attended to. A previous requirement to monitor and record the temperature of water outlets has now been met. The record of testing fridge and freezer temperatures was examined and provided evidence that the fridge is not functioning correctly: an immediate requirement was made for this to be replaced. Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 2 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 2 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 2 X X 3 X Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 21 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 YA1 Regulation 4 Requirement An application must be made to CSCI to vary the conditions of registration to reflect the ages of the people currently living in the house. Care plans should be developed as indicated in the main body of this report, to include more detail about how support is given, to expand communication guidelines, to set goals with measurable outcomes and evaluate them at review. (See requirement no. 4 below also) (Partially met) Develop risk assessments as indicated in the main body of this report, and cross-reference to the care plan(s) to which they relate, and vice versa. (Partially met) Further develop the range, quality and frequency of activity opportunities for residents, and seek help for staff to enable them to support residents with communication support needs better. (See no. 7 below also) Timescale for action 30/04/06 2. YA6 15 (1) 31/05/06 3. YA9 13 (4a-c) 31/05/06 4. YA12YA13 16 (2m-n) 30/11/05 Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 22 5. YA12YA13 16 (2m-n) 6. YA19 12 (1-3) 7. YA24 23 (2d) 8. YA33 18 (1a) 9. YA34 19 Sch 2 & 4 10. YA35 18 (1c) 11. YA36 18 (2) 12. YA39 26 Expand activity recording so that clear links can be established between activity opportunities and individuals’ assessed needs and agreed goals. Develop epilepsy care plan and give clear guidance about monitoring and recording of seizures. Make arrangements for the communal areas of the home to be redecorated. (Outstanding since 31/12/06) Repaint the front door. Replace the fridge in the kitchen Recruit to fill vacant posts and allocate staff hours to improve the frequency and range of activities available to people living in the house. (See no. 4 above also) (Partially met) Ensure that all records required by regulation (Care Homes Regulations 2001) are maintained in respect of each person working in the home. Forward the staff training and development assessment and plan to CSCI, providing information detailed in the main body of this report. (Outstanding since 30/11/05) Ensure that staff receive training in supporting people with (1) epilepsy and (2) autistic spectrum disorders. Ensure that all members of staff receive formal supervision at least six times in any 12-month period (pro rata for part-time staff), and keep a written record of each meeting. The Registered Provider must ensure that visits and reports required under Regulation 26 (Care Homes Regulations 2001) are completed at least once a
DS0000016937.V284203.R01.S.doc 31/05/06 30/04/06 31/05/06 30/04/05 31/05/06 30/04/06 31/05/06 31/05/06 Walsall Road, 804 Version 5.1 Page 23 24 13. YA42 13 (4) month. A report of quality assurance and monitoring activity in the home should be sent to CSCI, and this should show clearly how the views of residents have been taken into account in the review and development of the service. Ensure that the fire alarm is tested weekly and a written record kept. (Outstanding since 08/09/05) 30/04/06 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 YA23 Good Practice Recommendations Cross-reference Adult Protection Policy to current local multi-agency guidelines. (Not assessed) Walsall Road, 804 DS0000016937.V284203.R01.S.doc Version 5.1 Page 24 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
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