Inspection on 04/11/05 for West Heath House

This inspection was carried out on 4th November 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 no outstanding requirements from the previous inspection report, but made 11 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 17/02/06

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 4th November 2005 10:30 West Heath House DS0000024906.V264866.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 West Heath House DS0000024906.V264866.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. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 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.V264866.R01.S.doc Version 5.0 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 First inspection 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.V264866.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors conducted this inspection over the period of one day. This is the home’s first inspection since registration in June 2005. The inspectors met and spoke to service users, staff and the registered manager about the care provided in the home. Records that describe how service users needs are to be met were sampled as well as some records of staff training and health and safety practice. A tour of the premises was undertaken and two service users invited the inspectors to look at their bedrooms. There have been no complaints received by the home or CSCI within the last six months. What the service does well: What has improved since the last inspection? What they could do better: Some areas of health and safety practice need to improve to protect the service users living at the home. Adult protection policy, procedures and staff training in this area require improvement. It is of concern that a reduction in staffing levels at night might have an impact on the care delivered to service users during this time. Conflicting evidence about staff training made it difficult to establish how training is planned and delivered. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 6 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.V264866.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 West Heath House DS0000024906.V264866.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): 2 There are effective systems in place to assess the needs of prospective service users before they are admitted to the home. EVIDENCE: The inspectors observed the assessment procedures for the admission of prospective service users to the home. In both cases information was seen to have been gathered from a number of sources including healthcare professionals and family members as part of the assessment process. The assessment procedure used by the home was noted to be linked to the development of an individual plan that describes how service users assessed needs are to be met upon admission. It was pleasing to note that service users had been included in the assessment process. For example, written agreements were observed that had been devised with the service user to describe the care that would be provided and the systems in place to monitor the outcome of the delivery of such care. West Heath House DS0000024906.V264866.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, 9 In the main, systems of individual planning and risk assessment are good and create positive outcomes for service users living in the home. EVIDENCE: Four individual plans of care were observed. All were seen to be well constructed with up to date information about the person’s needs with regard to their communication, mobility, personal and healthcare, cultural and spiritual needs and social and leisure needs. The individual plans seen were considered easy to read and well organised and included information about the ongoing involvement of rehabilitation staff based at the home to ensure that assessed needs continue to be met. For example two service users plans identified the need for input by an Occupational Therapist in order to assist them with independent living skills. Evidence was seen that programmes of rehabilitation had been devised and implemented to meet these needs. The inspectors spoke to five service users about their individual plans. All of the service users stated that they had been included in the development of their plans and had regular meetings with their key workers to reflect on the outcome of the plans in place. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 10 Risk assessments were observed within each of the four individual plans sampled. In all cases, there was evidence that the assessments had been reviewed on a regular basis and the assessments updated as a result of the review. The risk assessments seen demonstrated that service users are supported to take responsible risks based on the home’s assessment of their needs and skills. For example, one service user had been enabled to access the local shops independently following a period of monitoring by staff of the person’s skills to do so. It was noted that where risks had been identified, there were controls in place to manage them, such as the provision of 1:1 staffing and written guidelines to describe how staff must respond to service users that demonstrate behaviour that challenges the service provision. In one service user’s file it was noted that there was insufficient detail to describe how to respond to the person entering other service users bedrooms, which had been identified as a known risk. The written guidance instructed staff to “remove” the service user in the event that this happened. The guidance is in need of development to clearly record how this takes place and staff must be briefed with regard to their role within the process. West Heath House DS0000024906.V264866.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): 11, 16 Service users are supported by a team of trained staff to develop and maintain their skills in independent living. EVIDENCE: The home has a team of trained rehabilitation staff that are based on the premises and work with service users to enable them to develop their independent living skills. The team consists of Occupational and Speech and Language Therapists, Physiotherapists and Assistant Psychologists that are employed by the Brain Injuries Trust. The inspectors spoke to one of the Occupational Therapists who described her involvement with the service user group and explained that she makes an assessment of their skills over a ten-week period and provides a plan of rehabilitation based upon the outcome. Service users were seen to be involved in cooking in one of the two rehabilitation kitchens within the home and assisting with laundry tasks and cleaning their bedrooms as part of their independent living skills programme. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 12 One service user advised the inspectors that he did not have a key to his bedroom door. This was discussed with the registered manager who made assurances that the matter would be followed up. Service users were observed moving freely around the home and staff were seen to spend time with them in the dining room, garden and lounges. The home’s statement of purpose places emphasis on service users developing their independence through the rehabilitation process and as previously specified in this report, it was noted that service users have signed documents to state their agreement to skills linked programmes or routines of rehabilitation. The inspectors noted that a number of service users that smoke had their cigarettes given to them at intervals during the day. Written guidelines were seen to be in place to provide a rationale for this limitation based upon the service users’ needs. West Heath House DS0000024906.V264866.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): 18, 19 There are systems in place to assess service users personal and healthcare needs. A reduction in staffing levels at night may have an impact on the quality of personal care delivered to service users. Some development of care planning is needed to ensure that service users with continence problems have appropriate support in accordance with their assessed needs. EVIDENCE: The individual plans sampled showed that service users personal care needs had been assessed and their preferred routines had been incorporated within the plan of care. Evidence was seen in the form of assessments made by the Occupational Therapy team that service users who require assistance from staff and/or specialised equipment had guidelines in place to instruct staff how to meet their personal care needs. The inspectors spoke to three service users about the arrangements within the home for getting up and going to bed and were told that this is flexible. A number of service users were reported to require the assistance of two members of staff to meet their personal care needs at night. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 14 The home’s rota showed that night staffing levels were to be reduced from four to three staff from 6/11/05. The inspectors queried the rationale for this change in light of the assessed needs of the people living in the home and made immediate requirements that the CSCI be advised of this, in writing by 8/11/05. This matter is further discussed in Standard 33 of this report. The individual plans sampled demonstrated that service users health care needs had been assessed prior to their admission to the home and that there are monitoring systems in place to respond to any changes to those needs. For example, records showed that regular clinical reviews take place, which are attended by the rehabilitation team, psychology services and the Consultant in Neuropsychology and Rehabilitation. Two service users individual plans showed that comprehensive guidelines were in place to respond to their epilepsy and charts were seen to be in place to record the frequency, duration and type of seizure that occurred. A member of staff advised the inspectors that these records were collated for monitoring purposes and subsequent discussion at service users healthcare reviews. One individual plan identified that a service user has continence problems and uses a conveen, however there was no evidence of a plan of care to describe how these needs were managed. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 15 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 Some development of the home’s procedures in responding to allegations, disclosure or suspicion of abuse are in need of development to protect the people living in the home. Staff training in adult protection was not evidenced at this inspection. EVIDENCE: The home’s adult protection policy was observed and found to contain some information that is not in keeping with the good practice guidance issued by the lead agency for adult protection, Birmingham Social Services Department. For example, the policy referred to the service manager “making a decision whether to authorise an internal investigation if no criminal offence is alleged” and under the summary of action stated “if an adult abuse investigation is appropriate contact Social Services and the CSCI”. Allegations, disclosure or suspicion of abuse must be referred to the Social Services Department whose officers will take the lead on determining the course of action to be taken and instruct the home accordingly. It was however, pleasing to note that the registered manager had taken appropriate steps to refer an adult protection matter to the Social Services Department and had advised the CSCI of this event without delay. The staff training records observed did not evidence that all staff had received training in adult protection. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 The home is clean and warm and staff have made effort to create a homely atmosphere in some areas of the building. Service users are able to bring personal possessions with them to furnish their bedrooms when they move into the home. There are effective procedures in place to control the spread of infection within the home. EVIDENCE: West Heath House is a purpose built care home and is not presented in keeping with other residential properties in the area. The premises are not considered to be commensurate with a domestic dwelling, however it is accepted that the purpose of the home is not to provide service users with a long term placement but to enable rehabilitation prior to the person moving on to a more permanent setting. It is however evident that staff have made efforts to personalise areas of the home by use of pictures, photographs and comfortable seating placed in hallways and communal rooms. The home is situated close to local amenities such as shops, pubs and cafes and places of worship. There are public transport links within walking distance. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 17 One service user talked about going out to the shops on a regular basis and another said that he had joined a local leisure centre. The bedrooms seen were noted to be warm, comfortable and well furnished. Two service users said that they had been able to bring their personal possessions with them when they moved in to the home, such as ornaments, television sets and stereos. It was noted that one service user’s en suite shower had leaked over the bedroom carpet, which the person said happened on a regular basis. The laundry room is situated away from areas where food is stored, prepared and eaten. It was reported by staff and evidenced within individual plans and daily records that service users are supported to do their own laundry where this forms part of their plan of care. The registered manager described the system of moving soiled linen from bedrooms and bathrooms to the laundry, which was consistent with effective infection control practice and the home’s written policy. Clinical waste bins were seen to be in place throughout the building and the inspectors were advised that the home has a contract for the regular removal of clinical waste. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 18 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): 33, 35 The proposed reduction in staffing levels at night may have an impact on the delivery of care to service users at night. The training records seen did not demonstrate that the home has a system of assessing the needs of staff and providing training that will enable them to meet service users needs. EVIDENCE: The home’s rota was examined and showed that eight members of staff are on duty between 7am and 2.30pm and seven members of staff conduct a shift from 1.30pm until 9pm. At present four staff are employed to work waking nights, however it was reported that this number is to reduce to three from 6/11/05. The inspectors queried the reasoning for this reduction as those records examined indicated that service users require support at night to manage their continence, in some cases with the assistance of two members of staff and a number of service users require help to shower during the night as a result of continence problems. A number of individual care plans identified that service users demonstrate challenging behaviour and might harm themselves or others as a result of this behaviour and it was considered of concern to the inspectors that staffing levels had been reduced without evidence of these issues being addressed. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 19 The home’s record of staff training was observed to contain some conflicting information about the type of training provided. For example the matrix in place for residential support staff showed that fire safety, adult protection and manual handling training had not been undertaken or was out of date, which was reflected in the individual records sampled. A second training file was seen to identify that this training had taken place. It was therefore not possible to establish that the home has a system of assessing the needs of staff and providing training in accordance with those needs, including the provision of mandatory training. Immediate requirements were made that a copy of the training matrix be sent to the CSCI. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 20 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): 42 Some areas of health and safety practice are in need of further development to protect the service user group within the home. EVIDENCE: The home’s fire safety records were examined and showed that regular testing and servicing of the fire alarm system had taken place. It was however noted that a fire drill had not been conducted and immediate requirements were made that this be addressed within one week of the inspection. Upon scrutiny of a service user’s daily records it was discovered that an incident had taken place, which had not been reported to the CSCI under Regulation 37 of the Care Homes Regulations (2001). Again immediate requirements were made that all events which occur that are notifiable under this regulation be reported without undue delay to the CSCI. The maintenance records seen showed that periodic tests are made to monitor the temperature of hot water within the home. West Heath House DS0000024906.V264866.R01.S.doc Version 5.0 Page 21 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 3 X X X Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 2 X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X X 1 X 1 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Heath House Score 2 2 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000024906.V264866.R01.S.doc Version 5.0 Page 22 NA 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 YA9 Regulation 13(6) Requirement The written guidelines for the service user that enters the bedrooms of others must be reviewed to ensure that clear information is provided about how to move the person in the event that this is required. Any physical intervention strategies required as a result of such review must only be used by trained staff in accordance with Department of Health guidance. Service users must be offered a key to their bedroom door unless it is agreed that this is not in their best interests. Any limitation must be recorded and subject to regular review. Night staffing levels must reflect the needs and number of service users living in the home and a written rationale for reducing night staffing levels from 4 to 3 must be sent to the CSCI. The care plan for the service user with a conveen must be reviewed to include information about the way in DS0000024906.V264866.R01.S.doc Timescale for action 14/12/05 2 YA16 12(4)(a) 17(1)(a) Schedule 3(3)(q) 13(4)(c) 18(1)(a) 14/12/05 3 YA33YA18 08/11/05 4 YA19 15(1-2) 17(1)(a) Schedule 3(3)(l) 14/12/05 West Heath House Version 5.0 Page 23 5 YA23 6 7 YA23 YA26 8 9 10 YA35 YA42 YA42 which the person’s continence and conveen care is managed. 13(6) The adult protection policy must be reviewed to ensure that staff are instructed to refer incidents of abuse to the Social Services Department and staff must be briefed with regard to their role within this procedure. 13(6) Staff must receive training in adult protection. 23(2)(c) The en suite shower in bedroom 17 must be repaired to ensure that it does not leak onto the bedroom carpet. 18(1)(a)(c)(i) A copy of the staff training matrix must be sent to the CSCI. 23(4)(c)(iii) A fire drill must be conducted and records maintained of those who took part. 37(1-2) All accidents and incidents must be reported to the CSCI as required under Regulation 37 of the Care Homes Regulations (2001). 14/12/05 20/12/05 14/12/05 14/12/05 11/11/05 04/11/05 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.V264866.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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.V264866.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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