Inspection on 15/11/06 for Walsall Road, 804

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walsall Road, 804 23/08/07

Walsall Road, 804 14/02/06

Walsall Road, 804 01/09/05

Walsall Road, 804 21/01/05

Walsall Road, 804 29/09/04

Walsall Road, 804 08/03/04

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 Walsall Road, 804 Great Barr Birmingham West Midlands B42 1EU Lead Inspector Gerard Hammond Unannounced Inspection 15th November 2006 09:00 Walsall Road, 804 DS0000016937.V312991.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 Walsall Road, 804 DS0000016937.V312991.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. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walsall Road, 804 Address Great Barr Birmingham West Midlands B42 1EU 0121 358 0412 F/P 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) http/www.milburycare.com/home.html Milbury Care Services Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years. That the home can provide care and accommodation for one named service user over 65. 14th February 2006 Date of last inspection 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.V312991.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered from a range of sources prior to the visit being made to this service. These included previous inspection reports, service history and the pre-inspection questionnaire and incident reports completed by the Manager, and reports submitted on behalf of the Registered Provider. Direct observation and sampling of records (including personal files, care plans, safety records and other documents) were also used for the purposes of compiling this report. The Inspector was able to see all of the residents and meet with one of their relatives during the course of the visit: unfortunately, the degree of learning disability and communication support needs of some of the people living in the house meant that it was not always possible to seek their views directly. The Manager was formally interviewed and the Inspector was able to meet with other members of staff. A tour of the building was also completed. What the service does well: What has improved since the last inspection? A new way of helping people to set goals and to try and make sure that they are working has been introduced. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 6 There is also a new way of keeping a record of the activities that people get the chance to do. This is to help people decide if the things they are doing are what they really want, or if some other things ought to be tried. A specialist organisation for people who have both sight and hearing difficulties has been asked to give advice about supporting one of the residents, to help staff work with her better. Arrangements to support staff through supervision are improving. 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.V312991.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information required to support making choices about the service is available, but making this relevant to people with learning disabilities presents particular challenges. Opportunities are provided for prospective residents to try out service before making decisions about whether or not to use it. Residents’ support needs are appropriately assessed so as to provide a good basis for individual care planning. EVIDENCE: Previous inspection reports show that a Statement of Purpose and Service User Guide are in place as required. It should be acknowledged that providing relevant information in a suitable format for people with learning disabilities has to be addressed on an individual basis, according to communication support needs and personal capacity. There have been no new admissions since the time of the last inspection. The person most recently admitted was able to come and visit and “try out” the service prior to moving in. Assessments for two of the residents were sampled. Current detailed personal profiles are in place and attempts have been made to present these in a userfriendly format. Profiles are supported by a completed ELSI (Everyday Living Skills Inventory). It was also noted that referrals had been made to Speech and Language Therapy and Occupational Therapy Services following the update Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 9 of individual needs. Most importantly, a referral has been made commissioning a specialist assessment for one of the residents who has dual sensory impairment, and it is hoped that this will provide valuable guidance for staff, enabling them to improve the support given to this person. Walsall Road, 804 DS0000016937.V312991.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ support needs are well reflected in their care plans, but these need some development to improve the way in which goals are set and measured. This is important so that proper judgements can be made about what is working and what needs to be changed. People get support to make choices, but this is limited according to individuals’ abilities. Expanding the use of person-centred approaches, and developing people’s communication opportunities could improve this. Responsible risk taking is encouraged, so as to support people’s independence. Assessments need to be reviewed, to ensure that hazards are properly identified and control measures included in care plans. EVIDENCE: Care plans were examined and showed evidence of review within the last six months. A new format has been introduced to support this process; this includes places for setting short, medium and long-term goals. The way in which these records have been completed suggests that staff may need some support so as to make the most effective use of them. Some areas of support Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 11 need have specific goals (e.g. communication – refer to Speech and Language Therapist, and expand use of objects of reference and other non-verbal communication) while others (e.g. physical, personal hygiene, domestic skills) have none. It is recommended that goals be set for each area of assessed need, and that special attention is given to ensuring that the outcomes can be measured. These can then be evaluated when the plan is reviewed, and judgements made about what is working and what might need alteration. Risk assessments and care plans are clearly linked by use of indexing cross-referencing. Risk assessments were not examined in detail on occasion, but the last inspection report highlighted the need to review assessments to ensure that potential hazards are correctly identified, control measures included in care plans. and this risk and Direct observation showed that residents are supported to make decisions, but these tend to be restricted to fairly basic things such as making choices about what to have to eat or drink. Individual capabilities and learning disabilities are limiting factors, and this has to be acknowledged. Positive action has now been taken with regard to seeking to expand the communication opportunities for one resident with dual sensory impairment. Some work has already been done to make use of objects of reference, and it is hoped that, with specialist support for staff, that this can be extended and further developed. Evidence was also seen of the development of pictorial aides (including photograph albums) to support individuals to make choices about activities, menus etc. There is also evidence of the use of person-centred approaches, but this needs to be developed. Walsall Road, 804 DS0000016937.V312991.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to engage in some appropriate activities, but opportunities and the recording to support these, are limited. Activities should be clearly linked to individuals’ agreed goals and care plans, so that it is possible to see how people have exercised choice in what they do, and how this is being kept under review. People are well supported to keep in touch with their families and friends. Residents’ enjoy their meals and can make choices about what they have to eat. EVIDENCE: Previous inspection reports and current records show that residents are able to engage in appropriate activities and to access the local community. A new system for recording activities and evaluating them on a monthly basis has recently been introduced, and this should be commended. Activity recording for all three residents was examined. Staff advised that one resident, who has dual sensory impairment and complex support needs, can be difficult to engage. They are using a car key as an Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 13 object of reference to denote trips out of the house, and report that this is working quite well. However, if the weather is less than favourable, it can be difficult to get her to leave the home. It was noted that she had been out for meals on three occasions recently. A particular effort was made to take her to an Afro-Caribbean restaurant on her birthday, recognising her cultural needs. Her mother reported that she enjoyed this, and said that she is generally very happy with the service her daughter receives. Recording of in-house activities is limited to things like using foot spa, and head massage. It is hoped that improving communication opportunities for this person will impact positively on future activity options. Another resident was attending a local college, but this programme has unfortunately been suspended. However, he is now able to go to another centre once a week, where he is said to enjoy art activities. Records also show that he enjoyed a day trip to Weston recently, and that he likes to go out on the bus or in the car, visiting local shops and restaurants. He still uses the local barber and has been known there for a long time. However, recording remains poor and opportunities limited. A list of preferred activities was drawn up, but these activities are not well represented in the things actually done. Similarly, the other resident’s records show limited activity recording (going to the library, bought new TV, CD’s and DVD’s, (in house) cards, darts, watching TV etc.). Staff were observed encouraging residents to do as much for themselves as they can. It has to be acknowledged that this group of residents have high level of dependency, so this is restricted to fairly basic things. Staff recognise residents’ rights to decline activities offered and respect this accordingly. It should also be recognised that residents may make positive choices to remain at home rather than engaging in a wide range of activities externally, and this has to be respected. However, activity opportunities are a prime indicator of the quality of life that individuals enjoy. There should be clear links between what people do during the day and their individual care plans and agreed goals. Again, the development of person-centred approaches should support this overall process, by clearly identifying what things are important to each individual. Positive use needs to be made of the new tool for evaluating activities, and this must be supported with appropriate records. Positive comments were received from relatives of all three residents with regard to the standard of care received and the attitude of staff team. As reported above, the Inspector was able to meet with one person’s mother during course of the visit. Another relative wrote that staff went out of their way to support her brother keeping in touch with his family at all times, and in particular whenever opportunities arose for them to get together. Records show that all residents are in regular contact with families and loved ones. Residents were directly observed making choices about what to have for lunch and sitting up to the table to enjoy their meal. Menu choices are supported with pictorial aides, and the small size of the home facilitates alternatives at all times. Food stocks were examined: these were plentiful and included fresh Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 14 fruit and vegetables. Records of meals actually taken were also seen and provided further evidence that residents enjoy a varied and balanced diet that is appropriately nutritious. However, it was noted that there were some gaps in recording, and this should be addressed. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well cared for and appropriately supported to access primary and specialist healthcare so as to maintain good general health. This could be improved by developing individual Health Action Plans, so as to further promote their well-being. Residents are generally well protected by practice relating to the storage, handling and administration of medicines. EVIDENCE: As reported earlier, positive comments were received from all three residents’ relatives about the standard of personal care given. One wrote that her brother is “always clean and smart” and that staff are “very well mannered and they keep us informed about his health”. Another indicated that they are kept informed about important matters affecting their relative and consulted about their care appropriately. Direct observation of residents’ grooming and personal attire provided further evidence that residents receive a good standard of basic personal care. Interaction between staff and residents was seen to be warm and friendly and both are clearly comfortable in each other’s company. Records show that referrals are made to other professionals according to individuals’ assessed needs and that residents are assisted to access primary Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 16 and specialist healthcare support. These include GP, Consultant Psychiatrist, Gynaecologist, Speech and Language Therapist, Occupational Therapist, Continence Nurse and Chiropodist. It was disappointing to see that individual Health Action Plans have not been developed beyond a baseline assessment. One resident’s plan showed that there are issues with regard to limited mobility and weight loss. It was noted that the plan contained nothing about encouraging exercise and showed no link to his existing care plan about losing weight. Plans now need to be further developed as required. No one living in this house is able to take responsibility for his or her own medication. The Medication Administration Record (MAR) was examined and completed appropriately. There is a system in place for a second member of staff to check and sign that medication has been given correctly, in order to minimise the risk of administration errors. Prescribed PRN (“as required”) medication is generally supported by written protocols, though it was noted that one resident had no protocol in respect of Lactulose and this must be rectified. (Protocol forwarded following inspection visit). Written protocols must be signed and dated, and if possible countersigned by the prescribing doctor. The Manager is introducing a new system for auditing medication stocks. The medication store was secure, generally clean and tidy and in good order. The Accident Book was also examined. It is recommended that a prominent note be placed on the book to remind staff of the requirement to submit reports under Regulation 37 (Care Homes Regulations 2001). It was noted that the counterfoils had been marked with the initials of the person to whom reports related, and it is recommended that these are dated also. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is difficult to assess whether or not residents feel that their views are listened to and acted upon, due to their learning disabilities and communication support needs, but staff do their best to be sensitive to signs that people may be unhappy. People are generally protected from abuse, neglect or self-harm, but staff who have not yet received formal training in Adult Protection should now do so, so as to ensure residents’ safety further. EVIDENCE: As reported at the time of previous inspections, there is a complaints policy in place as required, but this has little relevance to the people living in this house, due to their levels of learning disability and communication support needs. No complaints have been received in respect of this service since the last inspection. Residents are generally reliant on the vigilance of the staff team and their sensitivity to changes in demeanour, behaviour and “body language” as indicators that something is amiss. It was good to note that each person’s personal record now includes a section “How I complain” to make staff aware of the ways individuals communicate that they are unhappy. The staff team is generally well established, and people have built up a good general knowledge of individuals’ particular ways, over a substantial period of time. However, it was noted from information provided in the pre-inspection questionnaire that a number of the staff team have yet to do training in adult protection, and this must be addressed. Examination of staff records relating to recruitment show that checks with CRB (Criminal Records Bureau) and under Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 18 POVA (Protection Of Vulnerable Adults) scheme have been carried out as required. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 19 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, 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 living in a house that is kept clean and tidy and provides them with a safe and comfortable home environment. Individual rooms are very personal and fitted to a good standard, enabling people to enjoy their personal spaces as and when they wish. Some work still needs to be done to bring the communal areas of the house up to the same standard. EVIDENCE: 804 is an adapted, domestic scale bungalow, generally well maintained, providing residents with a comfortable homely environment in which to live. People’s own rooms are individual in style, and possessions and personal effects in them reflect residents’ interests and tastes. One resident (the last person to move in) has now had his room refurbished and expressed himself very happy with the result. He said that he likes to spend time in there watching his DVD / video or listening to his favourite music. He particularly likes some of the old musical films and has a good collection. Another resident has his own tropical fish tank. The resident with dual sensory impairment and complex support needs has her own en-suite facilities. Her mother indicated that concerns have been expressed about the heating in her daughter’s room. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 20 This should be properly assessed and any remedial action required to ensure an even, comfortable temperature must be taken. At the time of the last inspection requirements were made in relation to redecorating the communal areas in the home. The Manager advised that this is temporarily “on hold” while advice is sought from the specialist organisation commissioned to carry out a functional assessment of the resident with dual sensory impairment. The Manager has direct experience of this herself, having been through a similar process in the home she managed prior to taking up her current post. One of the outcomes of the assessment will be recommendation about colour schemes, contrasts, textures etc. designed to improve the overall environment for people with sensory impairment. This should be followed through as a matter of urgency. The main bathroom is also in need of a significant “facelift”. In contrast with the rest of the house, this room is quite institutional in “feel”. The bath is damaged and should be replaced. Consideration should be given to the changing care needs of the residents, particularly in relation to deteriorating mobility, prior to carrying out this work. The home is kept clean, neat and tidy, and a good standard of hygiene maintained throughout. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 21 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): 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. Members of staff are competent, but there are significant deficits in training and qualifications required to meet fully the assessed needs of service users. Improvements must be made in order to ensure service users’ quality of care. Residents are protected by the organisation’s recruitment policies, which are backed up in practice. They also benefit from being cared for by staff that are appropriately supported and supervised. EVIDENCE: At the time of the last inspection concerns were expressed about significant gaps in the staff team’s training profile. Information provided with the preinspection questionnaire shows that the number of staff holding qualifications at NVQ level 2 or above is below the target minimum of fifty per cent. The staff training schedule also continues to show gaps in training in adult protection, autism, epilepsy and sensory impairment. Given the high level and complexity of the care needs of this group of service users, this issue must be taken seriously, and prompt action taken to address the identified shortfalls. It should be acknowledged that the current Manager has not had a great deal of time to address this, since taking up her post. Training is offered on a rolling programme within the organisation, and the Manager advised that the Training Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 22 Officer’s post is currently vacant. She said that she had been seeking alternative training options at local colleges in the interim. As reported above, this staff team is well established (eight of the current team have worked at the home for at least five years) and very familiar with the people in their care. Staff were directly observed supporting residents with patience and care. The records of three members of staff were sample checked. Recruitment is dealt with from a central location within the organisation. All documentation in support of the recruitment process was in place, as required. Records relating to staff supervision were also examined. While the level of supervision received by some staff was not up to the required standard at the time of the inspection visit, it is clear that the Manager has been very active in this regard, since commencing in post. Supervision sessions are now scheduled for all staff and it is anticipated that this will be up to standard in due course. Similarly, staff meetings are now taking place at appropriate intervals. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 23 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, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new Manager is working hard to try and ensure that the home is well run for the benefit of people using the service. Positive efforts have been made to evaluate the quality of the service provided, and this should be developed to show more clearly how residents’ views have been obtained and judgements made. Residents’ health and safety is generally well protected by policy and practice at the home. EVIDENCE: As reported above, there has been a change of manager since the last inspection. The current Manager has worked for the organisation for several years and ran another home, which has now closed down. Like her predecessor, she also has responsibility for another home situated further along the road. She is a qualified nurse (RNMH) and holds the Registered Managers’ Award and NVQ level 4. Members of staff indicated that she is very Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 24 approachable and has an open and inclusive style of management. One said, “She encourages staff development, works through ideas and supports staff with encouragement and praise. She has a positive attitude towards supporting residents”. A relative of one of the residents, who was at the home on the day of the inspection visit, said that she knew the Manager from one of her previous posts and was pleased that she is in charge of her daughter’s care again. A completed application to register the Manager should be submitted to CSCI. A copy of the home’s Quality Assurance report was provided. It is recommended that this be developed to show more clearly how judgements have been made about residents’ views and opinions. Reports required under Regulation 26 (Care Homes Regulations 2001) are generally completed as required. The staff team has also produced its own development plan, and this initiative should be commended and built upon. Safety records were sample checked. The fire alarm and emergency lighting systems have been serviced, and weekly tests carried out as required with a written record completed. Fire fighting equipment has been serviced, and fire drills been carried out at regular intervals. Temperatures at all water outlets have also been tested and records maintained appropriately. The COSHH store was secure. Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X 3 X X Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 (1) Requirement Timescale for action 28/02/07 2. YA9 13 (4a-c) 3. YA12 YA13 16 (2m-n) 4. YA19 13 (2) 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. (Partially met) Develop risk assessments so that 28/02/07 hazards are correctly identified, and control measures are included in individual care plans. (Partially met) Further develop the range, 28/02/07 quality and frequency of activity opportunities for residents, and seek help for staff to enable them to support residents with communication support needs better. (Partially met) Expand activity recording so that clear links can be established between activity opportunities and individuals’ assessed needs and agreed goals. Produce a protocol in respect of 31/01/07 Lactulose prescribed PRN (now met) Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 27 5. 6. YA27 YA28 23 (2) 23 (2d) 7. 8. YA32 YA33 18 (1c) 18 (1a) 9. YA35 18 (1c) 10. YA36 18 (2) 11 YA37 9 Replace the bath and refurbish the bathroom Make arrangements for the communal areas of the home to be redecorated. (Outstanding since 31/12/06) Ensure that at least 50 of care staff are qualified to (or actively working towards) NVQ level 2 Recruit to fill vacant posts and allocate staff hours to improve the frequency and range of activities available to people living in the house. (Partially met) Forward a revised staff training and development assessment and plan to CSCI, showing when outstanding training is to be delivered. Ensure that 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. (Part met) A completed application to register the Manager with CSCI must be submitted. 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 28/02/07 Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA7 YA8 YA19 Good Practice Recommendations Further develop the use of person centred approaches, so as to support residents’ choices and decision making more effectively. Develop residents’ Health Action Plans and set clear goals. Put a prominent note on the home’s accident book to alert staff to the requirement to submit reports under Regulation 37 (Care Homes Regulations 2001) Cross-reference Adult Protection Policy to current local multi-agency guidelines. (Not assessed) Develop quality assurance reporting to show more clearly how residents’ views have been obtained and judgements made. 3. 4. YA23 YA39 Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 29 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 Walsall Road, 804 DS0000016937.V312991.R01.S.doc Version 5.2 Page 30 - 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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