Inspection on 12/10/05 for 296 - 298 Warren Farm Road

This inspection was carried out on 12th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

296 - 298 Warren Farm Road 08/11/06

296 - 298 Warren Farm Road 02/06/06

296 - 298 Warren Farm Road 23/02/06

296 - 298 Warren Farm Road 18/03/05

296 - 298 Warren Farm Road 09/11/04

296 - 298 Warren Farm Road 25/02/04

296 - 298 Warren Farm Road 21/11/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Warren Farm Road, 296-298 Kingstanding Birmingham B44 0AD Lead Inspector Donna Ahern Announced Inspection 12th October 2005 10:00 Warren Farm Road, 296-298 DS0000030417.V249703.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 Warren Farm Road, 296-298 DS0000030417.V249703.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. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Warren Farm Road, 296-298 Address Kingstanding Birmingham B44 0AD 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) 0121 256 5005 Sense West Rosalind Ray Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One suitably qualified and competent member of staff and a sleep-in member of staff throughout the night, 10pm - 7.30am The home may provide care for 5 18-65 year olds with a learning disability and sensory impairments In addition to care manager, a minimum of 4 suitably qualified and competent staff are on duty throughout the working day at all times, 7.30am - 10pm 18th March 2005 Date of last inspection Brief Description of the Service: 296 - 298 Warren Farm Road is registered to provide personal care and support to 5 adults with a learning disability and sensory impairment, who have been assessed as requiring full assistance with daily living and other tasks. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for the service users. A number of adaptations have taken place within the home in order to meet the assessed needs of the service users. Service users are encouraged and supported to maintain links with their families and the local community. The care needs of the service users are monitored and reviewed and action is taken to address any concerns. The home is situated in the Kingstanding, a residential area of Birmingham and has ready access to local amenities. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one long day. The inspector met and spent time with all the residents. Due to the needs of residents they were not able to verbally express their views. A partial inspection of the physical standards was undertaken. Residents care plans and risk assessments were inspected. Staff records were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk to the manager and four care staff. An ExbyEx and his support from Sandwell People First were involved in part of the inspection and form part of the inspection team. As a service user Nigel has an expert opinion on what it is like to receive services for people who have a learning disability. Nigel’s comments are incorporated in this report. What the service does well: Warren Farm road is a safe comfortable house that has been well maintained. The home had additional adaptations so that it is suitable to accommodate residents with additional physical disabilities. Staff responded to resident’s different forms of communication and there was evidence through the course of the day that staff were committed to ensuring that residents were well cared for. Resident’s communication needs were documented in detail on sampled care plans. Residents were supported to access a range of activities in the home and the local community. The inspection team felt that the people who live in the home were unable to tell them what they thought about the staff. The impression was that the relationship between residents and staff was very positive based on the interactions they saw. They felt that staff knew a lot about the people they support and that the staff seemed happy and positive. The expert by experience said that he enjoyed the visit to the home he summed up his impression by saying that “Overall I felt the home to be of a Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 6 good standard with the staff and manager being very active about quality of care. The home very much felt like a person’s home and people seemed to have active lives. It is just very difficult to cater for 5 individuals in one home”. What has improved since the last inspection? What they could do better: Residents have very complex needs and additional health care needs. The provider must in conjunction with other professionals undertake assessments and ensure that they can meet the needs of specific residents as discussed with the provider. Risk assessments required more information so that they are really clear about what the risk is and the support required from staff. Care plans required some further work and development so that they contain a comprehensive support plan. Attention was required to how the information was presented as the files have a lot of information on them and it was difficult to find the most important information. There were concerns regarding the procedures in place and management of a resident’s epilepsy. CSCI required that the provider took some immediate Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 7 steps to address the concerns and safeguard the residents and staff. CSCI received a prompt and appropriate response from the provider who at the time of compiling this report was working alongside other professionals to ensure residents well being is protected. Attention was required to the management of resident’s medication. Improvements must be made to ensure that residents are protected by the homes procedures. Mealtimes and supervision of residents must be reviewed. The inspection team felt it would be better for staff to be more prepared so that the resident does not have to sit in front of their lunch for 10 minutes before they can eat it. Staff must have training and updates in mandatory areas so that they have the up to date skills and knowledge to support residents and meet their needs. The provider must review staffing levels to make sure that there are enough staff on duty throughout the day to meet residents needs. 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. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Information about the home required some minor updating so that prospective residents have the information they need to make an informed choice about the home. The provider must demonstrate their capacity to meet resident’s assessed needs. EVIDENCE: The Statement of Purpose had been updated so that it reflected the current situation in the home. There was evidence of ongoing work to The Service User Guide and additional pictures were to be added so that the document is more accessible to residents. The document will also be available on tape. Residents have very complex needs and some of the residents have additional complex health and medical needs. One of the outcomes of the inspection was that some further discussions were required regarding the providers capacity to meet some of the more clinical needs of residents. The provider has ensured that regular reviews have taken place on all residents and other relevant professionals have been involved in the process. Minutes of these minutes were available on file. Due to the deterioration and increased care needs of one resident the manager was advised to write formally to the placing authority to have a reassessment of their needs to ensure that the home was the most suitable placement. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 10 Contractual agreements were in place these required some additional information including bedroom details, fees and they required signing by the resident or their representative. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 11 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 and 9 Care plans were detailed documents. These required further development so that information is clear and accessible to staff regarding how to meet resident’s needs on a daily basis. Some further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: Comprehensive care plans were in place for each resident. Two were sampled. The care plans included detailed information on residents communication needs, their personal care routines, the range of activities that they are supported to engage in and how choices are to be offered. Information on the care plan was supported by a number of guidelines and advice sheets. The amount of information was overwhelming. The concern was that the important information and the information required to meet the residents needs on a daily basis would be lost in the wealth of information on one file. The manager had started to consider how the care plans could be improved and was reviewing the purpose of the advice sheets. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 12 The inspection team were able to discuss with staff peoples care plans. They was pleased to hear that the care plan was regularly looked at by the staff team and kept active. The resident’s needs are such that they were reliant on staff to interpret and respond to their needs and to assist with making choices on their behalf and in their best interest. Staff responded to resident’s different forms of communication and there was evidence through the course of the day that staff were committed to ensuring that residents were well cared for. Resident’s communication needs were documented in detail on sampled care plans. A number of risk assessments were available some required further development. Risk assessments regarding the support required by residents who have epilepsy were required. The manger explained that there was ongoing work to the risk assessments and guidelines’ regarding the support required by residents during the waking night and the manager was liaising with other professionals to ensure that best practice is in place for each resident. Progress will be monitored at the next inspection. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 13 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 and 17 Residents were supported to engage in appropriate activities, maintain links with their relatives. The arrangements for meals required some review. EVIDENCE: Staff in the home support residents to attend community based activities and engage in home based activities. The organisation has some facilities at their office head quarters in Selly Oak which residents are supported to access this includes massage and art facilities. Following relevant risk assessments the manager had recently changed the transport facilities so that that are fully accessible and safe for residents to use. The inspection team asked the staff about the type of activities people do during the week. They felt that the people that live at Warren Farm have similar needs in respect to people having sensory impairments. People like to be able to hear and feel things. They got the impression everybody does the same activities but at different times during the week. Some of the activities people do during the week are going swimming, a garden centre (where people are involved in making things), a sensory centre, a massage centre and shopping. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 14 In the evenings people like to go to the cinema, theatre, going for meals and the ladies also have night out together. The inspection team acknowledged it must be hard to find activities people with complex needs can be fully involved in and e felt that from talking to staff that they were really supportive in finding new ideas. In the home people have a sensory room they can access whenever they want to. The inspection team thought that this was excellent that they have a separate room, as its communal room for people to use. The inspection team had the opportunity to look around the home and said, “within the home it seemed people have other sensory objects they can hold. Music players were also in the home. As well as having a communal stereo people have there own stereo’s in their rooms, along with TV’s and DVD players. Its good people have the choice to be in the communal areas or use their bedrooms if they wish to listen to music or watch TV. Resident’s family and friends details were documented on their care plans. The organisation has a family liaison officer who offers support and advice to resident’s families. The inspection team spoke to staff about resident’s family contact. Staff said they try to make people’s friends and family welcome in the home and also encourage them to engage with people from their own culture. Staff said that although one of the resident’s families has moved away the resident’s family ring every night to speak to the resident and that they do take residents to visit their family. It was reassuring to hear, that residents have support to keep their relationship with their family. The inspection team spoke to staff about the arrangements for meals in the home. Staff said that people take it in turns to be supported to do the weekly shop for the home. On a Tuesday residents are supported to be involved in a ‘buy and cook day’. People go out and buy the food they would like to cook and eat. The inspection team thought this is a great idea and it would be excellent if people could do this more than once a week. Staff stated what the arrangements were for planning the weekly menus; the staff prepares the food, as they are confident they know what people like to eat. People are given a meal and if they do not like it they will push the food away and be given an alternative. The inspection team felt that staff should give the people a choice of what food they would like before they prepare the meal. And that staff could think about being creative in the way they offer choices to people. The inspection team had the opportunity to observe some of the lunchtime meal they observed that one of the residents had their lunch put in front of them. The staff member then went to get the medication. The lunch was left in front of the resident for about ten minutes. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 15 The inspection team were concerned they felt it would have been quite frustrating having lunch put in front of someone and not being able to eat it straight away. They felt it would be better for staff to be more prepared so that the resident do not have to sit in front of their lunch for 10 minutes before they can eat it. A requirement was raised to review this practice. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 16 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 and 20 Attention was required to aspects of medication and epilepsy management. Current arrangements raised concern about resident’s safety and welfare. Staff must be appropriately trained to administer P.R.N medication. EVIDENCE: Care plans had details of resident’s personal care needs. The manager had identified that additional work was required to these to ensure that all of the detail regarding resident’s personal care is documented. Manual handling guidelines were in place the manager was in the process of ensuring that a full manual handling assessment is in place for each resident as this is what must inform any guidelines. Manual handling training for staff was required. The training must be specific to the complex handling issues that are prevalent within the home. (The manger informed the inspector on 19/10/05 that the training had been scheduled for) There was a service record for the Malibu bath; confirmation that the service of the Rhapsody bath had been undertaken was required. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 17 The three hoists, two overhead and one mobile had been serviced and records of the test were available. Documentation indicated that residents are supported to receive medical input from a range of professionals. Health Action Plans had been implemented for all residents. The provider had appropriately instigated a multi disciplinary meeting regarding the ongoing care of one of the residents who has complex health needs and requires hospital admissions. Various health professionals were involved in the meeting and the outcome was that the home was appropriate to meet their assessed needs. The management of one resident’s epilepsy management required urgent review. The consultant had implemented a protocol and in addition the previous manager had implemented a protocol. Clarification was required regarding the protocol. Concerns were also raised about staff training, staff’s knowledge of the protocol and monitoring of the residents well being following a seizure and the administration of P.R.N medication. The provider responded immediately and appropriately to the concerns and demonstrated a commitment to safeguard the resident. Written confirmation of the organisations commitment to provide clarification and to address specific concerns was received on the 17/10/05. The procedure for the receipt, recording, storage, handling and administration of medication was assessed. The manager had revised the organisations medication policy and it was found to be a comprehensive document. Guidelines were in place regarding how each resident takes their medication. Staff were in the process of completing their training on the safe administration of medication Specific concerns were raised regarding the administration of a resident’s medication. The Medication record sheet indicated that medication had not been administered on three consecutive days. In addition there were gaps on other residents Medication Administration Record Sheets. An immediate requirement to investigate the errors was required. A protocol was required for one resident regarding the administration of paracetamol on a P.R.N basis. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 18 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 and 23 Some minor additions were required to the Complaints and Adult protection policy so that the home can fully demonstrate its commitment to listen to and protect residents. EVIDENCE: The complaints procedure was also available in widget format. The provider’s “summary of complaints” required some minor updating so that relevant contact names and details are accessible. None of the residents would be able to verbally raise their concerns. All five residents were reliant on the staff team to promote and protect their well being. The inspection team enquired what people do when they are unhappy and what the staff do. The staff said you are able to tell when someone is unhappy when you get to know the person. The staff will then go through a process of elimination to find out what is wrong with the person. For example they will check to see if the person is hungry or thirsty, check the environment to see if something is upsetting and so on. This is all recorded and the core team usually discuss any problems that need to be overcome to help the person. If it is something more serious staff said they tell the manager. The manager had dealt with a recent incident in the home, which had been referred to Social Care and Health as a protection matter. The manager and provider acted totally appropriately and the required procedures were followed and CSCI was fully informed. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 19 The organisations Adult Protection Policy required the flow chart to be completed so that in the event of a concern arising all the relevant contact details would be readily available for staff to follow. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 20 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 and 30 Residents live in a home that was, comfortable, safe, clean and well maintained. Additional adaptations had been incorporated to meet residents assessed needs. EVIDENCE: The home was purpose built for its registered category. Carpets had been cleaned which was a requirement of the previous inspection and the lounge carpet was to be replaced. The manager said that she was in the process of ordering new sofas that are appropriate for resident’s mobility and transferring needs. The manger was also looking at providing an alternative floor covering in the dining area so that good standards of hygiene can be maintained. Blinds for the windows were also on order these were assessed as the most appropriate window covering as they prevent a glare and felt to be most suitable for people with vision impairment. The inspection team felt that when they walked in the home they thought the building felt quite homely with lots of photographs on the walls. The home felt spacious and well maintained at a glance. The manager and staff said that the home was specifically made for the people that live at Warren farm and this shows positively. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 21 They really liked the different objects on the door that people are able to touch and see what room it is, an example is a wooden spoon on the kitchen door. To the rear of the home there is a large garden. The Inspection team were pleased to hear from the manager that the garden was being adapted for the people who live at warren farm. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 22 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, 33, 34, 35 and 36 Staffing levels and hours must be reviewed so that the home has an effective staff team, in sufficient numbers to meet resident’s assessed needs. EVIDENCE: Staffing levels are a condition of registration. The home was required to have four staff on duty throughout the working day (7.30-10.00). Examination of the rota indicated that there was five staff on duty; one of the residents had an additional staff member for six hours per day. The previous inspection report commented that the organisation was reviewing staff levels. An outcome of the inspection was that CSCI require a formal review of staffing to ensure that adequate staff are on duty at all times to meet residents assessed needs. Residents have very complex needs and require a high level of staff support to carry out their care plan and to engage in appropriate leisure and recreational opportunities. In addition the provider must ensure that a minimum of four staff are on duty between 21.30 and 22.00 when the change over of day and night staff takes place. There were 5.5 vacant posts, which was a high level of vacant post (third of the homes staff), which were being covered through bank and agency staff. There was some concern about the impact of vacant posts and the balance of agency staff and permanent staff. On the afternoon/ evening shift of the inspection there was two staff employed by sense and three agency staff on duty. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 23 The manager stated that all posts had been appointed to and the staff situation should now improve. Two staff had commenced employment and three other’s were waiting on start dates subject to relevant checks. The manger also spoke about some of the team building work, which was being planned as part of the work to reinforce good teamwork within the home. The inspection team observed that the people who live in the home were unable to tell them what they thought about the staff. An impression that the relationship between residents and staff was very positive was based on the interactions they saw. Staff knew a lot about the people they support and that the staff seemed happy and positive. Staff training records were assessed and identified that some updating was required. The manager acknowledged that this was an area that required her input. Some updates on Mandatory training were required. Adult protection training was scheduled for November 2005 and the manager had identified that moving and handling training was required for all staff and that the training must be specific to the complex needs of residents. As raised under standard 19 staff training specific to the epilepsy management of one resident was required. Four staff files were examined and there was evidence of a supervision structure in place and staff received regular supervision and was well on target to reach the minimum of six sessions per year. Staff recruitment records were fund to be satisfactory and were very well organised. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 24 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): There was an open and welcoming atmosphere, which benefits residents and staff. Some improvements were required to aspects of health and safety so that the home can evidence that resident’s health, safety and welfare are protected. EVIDENCE: The manager transferred from another Sense registered care home to be the acting manager in April 2005. In September 2005 she was successful in her fit person interview with CSCI and was approved as the registered manager. Throughout the inspection process the acting manager presented as open, positive and inclusive. The inspection team felt that the manager and staff team seemed to be really active and positive in providing the best quality of life for people who live at Warren Farm. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 25 There was evidence that much work had been done to improve systems, policies and procedures and clearly there was still further work required so that the home fully promoted the health safety and welfare of all residents. Some concerns were raised regarding epilepsy management and discrepancies in medication administration were identified which required immediate attention so that residents safety and welfare is fully protected1 as raised under standard 19 and 20. Staffing levels must be reviewed as raised in standard 33 so that there is adequate staff on duty at all times to meet residents assessed needs. Care pans and risk assessments on residents required further development. A number of required records were examined including risk assessments for the environment, fire records, health and safety and gas safety checks were all found to be in good order. The manger agreed to implement individual fire evacuation plans, which will incorporate the specific needs of each resident. Accident records were examined and there was evidence that the manager monitors and assesses each accident. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 26 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 2 X 2 X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Warren Farm Road, 296-298 Score 2 1 1 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000030417.V249703.R01.S.doc Version 5.0 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation Sch 4 17 (2) (2) Requirement The service user guide was under review and must be completed so that it contains all the required information. (Previous timescale 30/6/05). The provider must demonstrate the homes capacity to meet the assessed needs of residents. One resident needs required reassessment. CSCI must be informed of the outcome. The contract /terms and conditions must include fee and room details and be signed by the resident and their relative. Previous timescale 30/6/05) Care plans require some further development. (Some progress made further work required) Resident’s risks assessments required further development. (Some progress made further work required). The arrangements for residents receiving their meals and the supervision at meal times required review. Manual handling risk assessment must be completed. Manual handling training specific DS0000030417.V249703.R01.S.doc Timescale for action 31/12/05 2 3 4 YA3 YA3 YA5 14(1,2) 12(1) a, b 14(1,2) 12 1 a, b 5(1) (c) 31/12/05 31/12/05 31/12/05 5 6 YA6 YA9 15(1) (2) 13(4) a, b, c 13(4) 12 (1)b 13 (c) 13 (5) 13 (5) 31/01/06 31/12/05 7 YA17 15/11/05 8 9 YA18 YA18 30/11/05 31/12/05 Page 28 Warren Farm Road, 296-298 Version 5.0 to residents needs was required. 10 11 YA18 YA19 23 (2) (c) 12(1) (a) (b) The service of the one specialist bath required confirming with CSCI. The management and treatment of a resident’s epilepsy management required review. (Formal response received 17 10/05) Staff training in epilepsy management was required. The manager must ensure that medication administration sheets are always signed when medication is administered. The medication discrepancies identified must be fully investigated and the outcome reported to CSCI. A summary of the complaints procedure must be available in the home. The contact details on the adult protection procedure must be completed. Staffing levels must be reviewed and there must be four staff on duty till 10.00pm each night. Staff training records must be brought up to date. A copy of the training matrix with updates on mandatory training identified must be forwarded to CSCI. Fire evacuation plans were required for each resident. 30/11/05 17/10/05 12 13 YA19 YA20 18(1) (c) (i) 13(2) 17(1) a 3(i) 13(2) 17 (1) a 3(i) 22(7) 13(6) 18(1) (a) 18(1) (c) 12/11/05 13/10/05 14 YA20 17/10/05 15 16 17 18 YA22 YA23 YA33 YA35 31/12/05 31/12/05 31/12/05 30/11/05 19 YA42 23(4) (c) (iii) 30/11/05 Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It was recommended that resident’s files be culled and that the provider reviews the arrangements for presenting residents care plan information. Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 30 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 Warren Farm Road, 296-298 DS0000030417.V249703.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!