CARE HOME ADULTS 18-65
Walsall Road, 836 Great Barr Birmingham West Midlands B42 1JN Lead Inspector
Gerard Hammond Unannounced Inspection 18th November 2005 09:45 Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Walsall Road, 836 Address Great Barr Birmingham West Midlands B42 1JN 0121 358 0009 0121 358 0009 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 4 Category(ies) of Learning disability (4) registration, with number of places Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. Residents must be aged under 65 years with a learning disability. The home can continue to accommodate one named service user over 65 with a learning disability. That 836 Walsall Road apply for variation on behalf of future service users who reach the age of 65. That details regarding how the specific care and social needs of people over the age of 65 will be met must be included in the service users plan. Future admissions, and the Statement of Purpose be amended to reflect the age of service users accommodated. 4th May 2005 Date of last inspection Brief Description of the Service: 836 Walsall Rd. is registered to provide accommodation care and support for four adults with learning disabilities and is run by Milbury Care Services. The house is a detached bungalow and lies back from the main A34 Birmingham to Walsall road, being accessed via a good service road. It is situated in the Great Barr area of Birmingham, a short walk away from the Scott Arms shopping centre. The house is well served by public transport and conveniently located for a wide range of community facilities including shops, pubs, food outlets, libraries, places of worship and parks. Residents all have single bedrooms containing wash hand basins. There is a bathroom with facilities for assisted bathing, and a separate w.c. The lounge / dining room is situated at the front of the house. There is a small office, kitchen and separate laundry room, and wheelchair users can access the property both at the front and back of the house. The pleasant rear garden is enclosed and private. There is parking at the front of the property, both on and off road. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second visit of the current year: this report should be read in conjunction with the one written following the inspection completed on 21 June 2005. Direct observation and sampling of records (including personal files, care plans, safety records and previous inspection reports) were used for the purpose of compiling this report. The Inspector formally interviewed the Registered Manager, and also met with the newly appointed Deputy Manager and two of the residents. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
Clear efforts have been made to meet requirements set at the time of the last inspection. Residents’ contracts have been amended and updated. Some work has been done to develop care plans and risk assessments, and to develop new protocols relating to residents’ healthcare needs. Efforts have also been made to expand the range of activity opportunities available, including seeking new college placements and to obtain additional resources to fund extra days at specialist day services. The bathroom has had a major refit, including a new specialist assisted bath. In addition, a new skylight window has been fitted and this will significantly improve ventilation and temperature control.
Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 6 Formal staff supervision has been further improved so that this is now up to standard. The Deputy Manager has taken a lead role in monitoring and organising training related matters in the home. Most staff have now received Adult Protection training. Requirements to carry out and record testing of the fire alarm and emergency lighting systems, and to update the fire risk assessment, have now been met. 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, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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): 4, 5 Prospective residents are offered the opportunity to visit and to stay at the Home, before any decision is made about offering a placement. Residents now have individual written contracts as required. EVIDENCE: Standards 1 and 2 were assessed at the previous inspection, and met in full. One resident has moved to another home run by Milbury since the inspection visit, as he now requires nursing care. Knowledge of Organisation, and conversations with the Manager, confirmed that prospective new resident would be offered the opportunity to visit and to at the Home prior to any decision being made about a placement. A previous requirement to update residents’ contracts has now been met. last the any stay Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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, 8, 9 Care plans are being updated to include residents’ personal goals, and this should be developed further. Staff seek to consult with and involve residents in as many of the aspects of life in the home as their learning difficulties allow. Residents are encouraged to enhance their independence through appropriate risk taking, and this needs to be reflected in their care plans. EVIDENCE: It is clear that work is going on to further develop care plans and risk assessments, and this should be both encouraged and commended. Detailed ELSI’s (Everyday Living Skills Inventories) have been completed for each resident, and these should form a sound basis from which to update plans of care. Having clearly identified individuals’ support needs, work should now continue to develop plans in detail, showing precise information on how support should be given, and including individual goals with outcomes that can be measured. These will then provide a “benchmark” against which the
Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 10 effectiveness of the plan can be measured. It should be acknowledged that significant work has already been completed on this. As previously reported, risk assessments should be cross-referenced to the care plan(s) to which they relate, and vice versa. This will also continue to be a work in progress as plans are developed. The new computer templates for risk assessments should make a positive contribution towards this. Residents’ ability to be consulted on and to participate in all aspects of life in the home is restricted as a result of their learning difficulties. However, staff were observed asking residents what they wanted and seeking their opinions, throughout the course of the inspection visit. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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 Some good work has been done to improve activity opportunities for residents and this should now be built on. Activity recording needs to be expanded. EVIDENCE: Standards 11, 12, 13, 15, 16 and 17 were all assessed at the time of the last inspection, and 15, 16 and 17 met in full on that occasion. It was a requirement of the last inspection report that activity opportunities should be reviewed and developed, and some work has been done on this. One resident has made a specific request that she have an additional day at the centre she attends. This is a specialist facility for people with visual impairment, and she currently goes there on just one day each week. The Manager advised that she has made an application for the funding for this but that there is a delay in obtaining the necessary reassessment. The commissioning body should be contacted again, and this request pursued vigorously. It was also noted that one resident regularly refuses opportunities to go out to activities, and this was observed directly. Residents’ ages and preferences
Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 12 need to be taken into consideration when seeking to arrange suitable activities, and staff do try to deal with this appropriately. However, it is important that recording also includes activity opportunities offered but declined, so that the record is a true reflection of the overall situation. Further thought should also be given to developing home-based alternatives. The Manager also advised that residents had recently been enrolled on a local college network, and that this should offer them some additional opportunities. Staff continue to support residents to access local facilities in the community on a regular basis. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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): 19, 20 Residents’ healthcare needs are met appropriately. General practice with regard to the storage, handling and administration of medication is satisfactory, but one or two issues require attention. EVIDENCE: Standards 18 and 19 were assessed at the last inspection. Standard 18 was met in full, and a requirement was made under Standard 19 that the care plan for one resident needed to include appropriate guidance about the monitoring and management of one resident’s bowel care. A protocol has now been produced to deal with this area of support need. The Medication Administration Record (MAR) was examined and had been completed appropriately. Accompanying the record was individual guidance about how medication should be given, and a list of sample signatures of members of staff responsible for administration, as dictated by good practice. The medication store was clean and tidy. An immediate requirement was made that current protocols for all PRN (“as required”) medication should be produced, and it is recommended that these be filed with the MAR. It is further recommended that photocopies of prescriptions should be kept with the MAR, to assist in the identification of any prescribing errors.
Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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): 23 General practice provides residents with protection from abuse, neglect and self-harm. EVIDENCE: Standard 22 was assessed at the time of the last inspection. An outstanding requirement from previous inspections with regard to the provision of training in the Protection of Vulnerable Adults From Abuse has now been met. All members of staff have now received training, apart from one person whose training is scheduled in January 2006. Residents’ personal money was checked: the balance held tallied with the written account in all cases, and was supported by receipts for expenditure incurred. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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): 29 Residents now have access to specialist bathing equipment required. EVIDENCE: Standards 24, 27 and 30 were all assessed at the last inspection and met in full. Major improvements have now been made to the bathroom. A new specialist bath has been installed and staff trained in its use. The skylight has been replaced and this should help to provide a resolution to the ventilation problems experienced in the past. A couple of small jobs remain outstanding since the refurbishment work was completed: the extractor fan and some of the plasterwork in the separate w.c. are in need of repair or replacement. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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): 32, 34, 35, 36 Residents are supported by an appropriately qualified staff team. Recruitment policy and practice generally provides residents with adequate protection, but some issues regarding required documentation need to be addressed. Training opportunities are provided for all staff members. A current staff training and development plan is required. Staff are supported and supervised appropriately. EVIDENCE: There have been a number of personnel changes since the time of the last inspection. The Manager advised that the new Deputy Manager has taken an active role in supporting and organising matters relating to staff training, and considers this a positive move. Conversations with the Manager indicate that the number of staff qualified to NVQ level 2 and above exceeds the minimum required. Two other members of staff are waiting to be allocated places to study towards NVQ2 as soon as these become available. One member of staff has completed LDAF (Learning Disability Awards Framework) training, and another is part way through this also. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 17 The personnel records relating to the most recently recruited member of staff were examined. A CRB check had been completed, and there was documentary evidence of proof of identity and a completed application form and declaration of physical fitness for the job. However, there was no recent photograph, only one reference, and no evidence of the person’s right to work in this country. Also, the copy of the contract held on file had not been signed by the employee. The Manager advised that all the necessary documentation had been obtained, and it should be acknowledged that such documents are processed at a central location within this organisation. However, attention is drawn to the requirements of the Care Homes Regulations 2001 in respect of records which must be kept for all persons working in a care home, and which must also be available for inspection. It is recommended that a checklist of all required documentation should be filed on each employee’s personal record to support this process more effectively. An amended training and development plan is now required in respect of the current staff team, to reflect the recent changes in personnel and to bring the plan provided following the last inspection up to date. As previously indicated, the plan should indicate (for each member of staff) details of qualifications obtained and training completed, and highlight any gaps including “refreshers” or other training required. The plan should also specify when outstanding training is scheduled and who is to deliver it. It should be acknowledged that this Organisation operates a rolling programme of training and seeks to make provision for all members of staff to access training opportunities as required. At the time of the last inspection it was noted that the frequency of staff supervision had improved. On this occasion it was noted that this improvement has been maintained and extended since then, so that this is now generally very much “on track”. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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, 38, 39, 42 Residents benefit from living in a home that is generally well run, with an open and accessible style of management. The results of quality assurance monitoring are required in order to make a proper judgement about whether or not residents’ views underpin development within the home. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: The Manager is qualified to NVQ level 4 and is working towards the Registered Manager’s Award, which she is hoping to have completed by spring 2006. She demonstrates a positive attitude towards developing the service for the benefit of the people living in the house, and makes clear efforts to address issues raised and to meet requirements. The management approach is open and inclusive, and there appears to be a good working relationship between members of the care team in general.
Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 19 A requirement was made at the last inspection that the new system for quality assurance and monitoring should be implemented, taking particular account of the residents’ communication needs, so as to represent their views appropriately. The Manager advised that information relating to this has been forwarded to senior managers within the Organisation. The outcome of these deliberations should now be made available to interested parties, and a copy sent to CSCI. Fire safety records were examined: a recent report from the local Fire Officer recorded no problems, and it was noted that the fire risk assessment has recently been reviewed. Checks on the fire alarm and emergency lighting systems have been carried out and a record kept, as required. Fire evacuation drills are also carried out regularly. The record of these should include the names of all those taking part. Records were also seen of checks on temperatures of the fridge and freezer, water, and COSHH cupboard. The COSHH file was also examined and contained relevant product information. Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X 3 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Walsall Road, 836 Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 3 X DS0000016938.V268276.R01.S.doc Version 5.0 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 YA6 Regulation 15 Requirement Review care plans and set targets with measurable outcomes. Ensure that records of reviews show who takes part, and how decisions are made. Residents’ whole care plans should be reviewed every six months at least. (Partially met) Review risk assessments in conjunction with care plans. Ensure that risk assessments are appropriately cross-referenced with relevant care plans, and that indeces are current and accurate. Review and further develop the range of activity opportunities available to residents. Actively pursue funding for additional specialist day centre session, and develop home-based alternatives also. Ensure that protocols are in place for all PRN (“as required”) medication. (Immediate requirement) Ensure that all documentation required in respect of every
DS0000016938.V268276.R01.S.doc Timescale for action 28/02/06 2 YA9 13(4c) 28/02/06 3 YA12YA13 16(2m-n) 28/02/06 4 YA20 13 (2) 19/11/05 5 YA34 19 Sch2&4 31/01/06 Walsall Road, 836 Version 5.0 Page 22 6 YA35 18(1c) 7 YA39 24(1-3) 8 YA42 13(4) person working in the home is maintained and available for inspection. Submit to CSCI a detailed and 28/02/06 current staff development and training assessment. This should clearly indicate the training that each staff member has received, and identify when refreshers or further training is due. It should also indicate when training is scheduled and who is to deliver it. Produce the findings of the new 28/02/06 quality assurance and monitoring system, and forward a copy to CSCI. Ensure that records of fire 28/02/06 evacuation drills include the names of all those taking part. 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 YA20 Good Practice Recommendations Retain photocopies of prescriptions with the Medication Administration Record, to support the identification of prescribing errors. Place a recent photograph of each resident on his or her MAR. Produce a template checklist of all documents required to be retained on individual staff members’ personal files. 2 YA34 Walsall Road, 836 DS0000016938.V268276.R01.S.doc Version 5.0 Page 23 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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