Inspection on 17/02/06 for West Heath House

This inspection was carried out on 17th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Heath House 07/11/08

West Heath House 31/01/08

West Heath House 26/07/06

West Heath House 04/11/05

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

CARE HOME ADULTS 18-65 West Heath House 54 Ivy House Road West Heath Birmingham West Midlands B38 8JW Lead Inspector Julie Preston Unannounced Inspection 17th February 2006 12:00 West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West Heath House Address 54 Ivy House Road West Heath Birmingham West Midlands B38 8JW 0121 459 0909 0121 459 0910 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) Brain Injuries Rehabilation Trust Mr Harminder Singh Kalsi Care Home 25 Category(ies) of Physical disability (25) registration, with number of places West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That home can accommodate up to 25 younger adults aged between 18-65 with acquired brain injury (25 PD) in receipt of personal care. The manager achieves NVQ level 4 in care before April 2006. Date of last inspection 4th November 2005 Brief Description of the Service: West Heath House is a purpose built care home for up to 25 adults with physical disabilities and acquired brain injury. The building is single storey and all bedrooms have en suite facilities. Communal areas consist of three lounges, two rehabilitation kitchens and two dining rooms. There are a number of rehabilitation staff working at the home that have office space and treatment rooms on the premises. The home is situated close to local amenities and public transport routes. The home is accessible to people that use wheelchairs and a number of aids and adaptations are provided in the home to assist them to manage their personal care. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over half a day and included discussion with service users about their experience of living within the home, observation of service users records, staff training and recruitment records. The inspector had lunch with service users and followed up on requirements made at the last inspection. This report should be read in conjunction with the report made following the visit of 4th November 2005. What the service does well: What has improved since the last inspection? 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. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 6 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 West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 7 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): None of these standards were assessed. EVIDENCE: West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 8 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): 7 Service users have opportunities to make decisions about their lifestyles. EVIDENCE: The inspector spoke to service users about the opportunities they have to make decisions about their lives. Service users stated that they can go out alone where it has been agreed with them and staff working in the home that this is safe to do so. One service user confirmed that he had been provided with a key to his bedroom door. Examination of individual financial records showed that service users make choices about how to spend their money and receive assistance from staff where this is needed. The home operates a system of planning meetings where service users and staff agree rehabilitation tasks such as shopping, cooking and menu planning. Daily records sampled showed that in the event of a service user not wishing to participate in an agreed task, the person would be prompted by a member of staff later in the day. The home conducts a “client forum” every fortnight, to enable service users to discuss issues that are important to them in an open setting. Service users were observed to attend a forum meeting at this inspection. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 9 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): 11, 12, 13, 15, 17 Service users have opportunities to go out and do things they enjoy and to keep in touch with their families and friends. Service users enjoy their meals and are included in food preparation and cooking. EVIDENCE: The inspector had the opportunity to meet a Speech and Language therapist who works at the home. The therapist described providing training to staff to enable them to communicate and engage with people who have experienced brain injury. The staff team have made considerable effort to provide service users with information that is reflective of their communication skills and needs. Widgit symbols have been used to depict rehabilitation tasks and some work has progressed to develop the fire and complaints procedures by use of photographs and symbols. From discussion with service users and examination of activity plans and daily records it was evident that service users have opportunities to go out and do West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 10 things they enjoy such as swimming, gardening, trips to the gym, cinema, local church and leisure centre. Within the home, service users were observed to be engaged in cooking, client meetings and arts and craft activities. The home has a visitor’s policy which is made available to service users and their friends and relatives. Examination of daily records showed that service users receive visitors to the home and spend time with their friends and relatives outside West Heath House. The inspector had a meal with service users and noted that several choices were available. Due to the number and needs of the service user group, the home has a large industrial style kitchen, which is staffed by two cooks. Smaller, domestic type kitchens are available for service users to cook their own food in, as part of individual rehabilitation programmes. Staff reported that snacks and drinks are available outside regular mealtimes and this was confirmed by three service users during the inspection. Service users made positive comments about the meals provided at the home. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 11 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): 20 At the time of the inspection the medication records did not reflect accurately what had been administered to the service users in all instances but good systems for medicine management had been installed in the home and the manager was keen to improve practice further. EVIDENCE: The pharmacy inspector from the CSCI visited the home on 1/3/06 and made the following comments – General audits demonstrated that the majority of medicines had been administered as prescribed and recorded as such but this was not seen for all medicines audited. The home had a system installed to check all the medicine received from the pharmacy. One medicine was constantly running out due to insufficient quantities being prescribed to last the 28-day cycle. This had not been addressed with the doctor or its use reviewed. In addition from the prescriptions supplied and the quantity received more tablets had been recorded as administered than received for this medicine. Staff routinely record the quantities of medicines received but do not record carry over balances from previous months so it was difficult to audit these medicines to demonstrate that they had been administered as prescribed. The doctor had changed one dose but the MAR chart was ambiguously written resulting in the medicine not being administered as the doctor intended. Many “when West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 12 required” medicines prescribed had supporting protocols, but this was not inclusive of all medicines. At the time of the inspection no service user was self-administering their own medication. The medicine policy included selfadministration but no risk assessment protocol was available. There was no routine assessment of staff to demonstrate competence in medicine management. All staff had undertaken accredited training in the safe handling of medicines. The manager was proactive during the inspection and was keen to improve practice further. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 13 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 There are procedures in place for service users and their representatives to make complaints. In the main there are procedures in place to protect service users living in the home. Some development of individual strategies is needed to make sure that physical intervention takes place according to agreed protocols. EVIDENCE: The home has a complaints procedure, which is currently being developed to provide a more accessible format for service users. The procedure is in need of minor amendment to include the contact details of the CSCI, so that service users are aware they may approach the Commission at any time for the purpose of making complaints. The inspector spoke to four service users who said they knew they had the right to complain and felt comfortable in approaching staff or the registered manager. The complaints log was examined, which showed that service users complaints are listened to and actions taken to address them. The CSCI had received one complaint about the home since the last inspection, which was discussed with the registered manager at this inspection. Referrals under adult protection procedures were noted to have been made by the home in response to incidents between service users. Within the records sampled it was evident that individual care plans and risk assessments had been reviewed following these incidents. Staff have received training in physical intervention, although training in adult protection is outstanding for some staff. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 14 One service user’s plan described the need for staff to “remove” the person under specific circumstances. This does not provide sufficient detail to enable the reader to determine how to do so safely in accordance with agreed physical intervention techniques. The home’s rota identified three members of staff to be working a waking night shift with additional staffing for service users that need 1:1 support. It is a requirement of this inspection that staffing levels remain subject to review based on the needs of the service user group and takes into account the number of events, which take place at night where individuals are at risk of harm from each other. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Requirements made at the previous inspection to repair a leaking shower unit in a service user’s bedroom had been met. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Service users are supported by a competent team of trained staff. The systems of recruiting new staff are robust and protect service users living in the home. EVIDENCE: Staff were observed to work with service users in a manner considered to be friendly and respectful. The inspector spoke to four service users who made the following comments, “the staff are great here, they help you out”, “people have really tried to help me”, “they’re a good bunch, they try really hard to get you to do things” and “this is the best place I’ve been to, nice people”. Some service users need 1:1 support for periods during the day and this was reflected in the daytime staffing rota observed. Observation of the home’s staff training matrix showed that sessions had been provided in moving and handling, behavioural monitoring and physical intervention. The Brain Injuries Trust provides the staff team with training about acquired brain injury at both basic and intermediate level. Staff recruitment records were sampled which contained a completed application form, evidence of satisfactory Criminal Records Bureau check, two written references and proof of identification, including a photograph. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 17 The records sampled demonstrated that new members of staff had received an induction programme prior to beginning work with service users. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home is well managed for the benefit of the people who live there. There is a system of quality assurance, which seeks the views of service users in the development of the home. Service users health and safety is promoted and protected. EVIDENCE: The home has a registered manager who has over twenty years experience of working in adult services. The registered manager has demonstrated compliance with requirements made at the previous inspection and a commitment to improving practice in medicines management and developing effective communication formats for service users. The registered provider makes regular visits to the home in order to report on the standard of care provided. The registered manager and CSCI have received copies of these reports. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 19 The Brain Injuries Rehabilitation Trust (BIRT) has a system of quality assurance, which seeks the views of service users, their families and referrers to the care home. The inspector observed a recent report that stated 75 of service users were satisfied with the service provided. The report went on to say that BIRT aimed to increase this figure to a “90 overall satisfaction rate within the coming months”. The home’s fire safety records were examined, which indicated that the fire alarm system is tested and inspected on a regular basis. Records were observed of maintenance and service to the assisted bathing facilities within the home. Regular fire drills are conducted, which are recorded. Staff training records sampled showed that fire safety awareness, moving and handling and first aid training is provided as part of a rolling programme. West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 3 X X 3 X West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement The quantities of all medicine balances carried over from previous cycles must be recorded to enable audits to take place to demonstrate that the medicines are administered as prescribed. All dose changes must be accurately written to reflect the doctor’s instructions to ensure the medicines are administered as the doctor intended. All “when required” medicines must have a supporting written protocol to reflect their use as prescribed by the clinician. A risk assessment protocol must be written to assess all service users wishing to selfadminister their own medicine. Staff drug audits before and after a drug round must be undertaken to demonstrate competence in medicine management. The complaints procedure must be amended to ensure DS0000024906.V284371.R01.S.doc Timescale for action 03/03/06 2 YA20 13(2) 03/03/06 3 YA20 13(2) 02/04/06 4 YA20 13(2) 02/04/06 5 YA20 13(2) 15/03/06 6 YA22 22(7)(a, b) 28/04/06 West Heath House Version 5.1 Page 22 7 8 YA23 YA23 18(1)(a)(c)(i) 13(6) 13(4)(c) 13(6) 9 YA23 13(4)(c) 18(1)(a) service users and their representatives are aware that they may complain directly to the CSCI. All staff must receive training in adult protection. Physical intervention strategies must be clearly recorded in service users’ plans so that staff are aware of the agreed techniques for intervention. Night staffing levels must reflect the needs and number of service users living in the home. This must be kept under review with appropriate records maintained. 28/04/06 05/04/06 28/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 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 © 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 West Heath House DS0000024906.V284371.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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