CARE HOME ADULTS 18-65
Wood Lane, 135 Handsworth Birmingham West Midlands B20 2AQ Lead Inspector
Gerard Hammond Unannounced Inspection 2nd March 2006 10:35 Wood Lane, 135 DS0000016881.V285850.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 Wood Lane, 135 DS0000016881.V285850.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. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Wood Lane, 135 Address Handsworth Birmingham West Midlands B20 2AQ 0121 523 5547 0121 523 5547 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) londonroad@tiscali.co.uk Milbury Care Services Limited Damien Crossan Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users must be aged under 65 years Service users must have a learning disability. The home may accommodate one named service user over the age of 65 years with a learning disability. The home must periodically review that it can still meet the needs of the named service user over 65 years, and a record of these reviews must be retained in the home. That Damian Crossan obtains the Registered Managers Award or equivalent by April 2005. 10th October 2005 5. Date of last inspection Brief Description of the Service: 135 Wood Lane is registered to provide accommodation, care and support for four people with learning disabilities. The house is a two-storey semi-detached property and is located in a pleasant and well-established residential area in the Handsworth district of Birmingham. Accommodation is provided in two single and one shared bedroom. One of the single rooms is on the ground floor. There are two bathrooms in the house, one on each floor. Downstairs there is also a lounge, separate dining room, kitchen and laundry. Upstairs, in addition to the shared and single bedrooms, there is a small office. There is an attractive enclosed garden to the rear of the property, and this has a lawn, planted borders and a small patio area. At the front of the house is a paved area with limited off-road parking. There are local shopping facilities within walking distance, and main bus routes also run close by. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second visit in the current inspection year, and was unannounced. This report should be read in conjunction with the one written following the inspection carried out on 10 October 2005. Direct observation and sampling of records (including personal files, care plans, safety records and previous inspection reports) were used for the purposes of compiling this report. A tour of the building was also completed. The Inspector met all of the residents, but people’s communication support needs and learning disabilities meant that it was not possible to interview them or seek their views directly. The Registered Manager was formally interviewed. What the service does well: What has improved since the last inspection?
Some work has been completed towards meeting requirements made at the time of the last inspection. Care plans are works in progress, and new formats are gradually being introduced. There is also evidence of person-centred approaches being included in the development of individual plans. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 6 The complexity of the care needs of one resident in particular has been recognised to require improvements to be made to the staff complement. One to one support is now being provided, and waking night cover. A requirement to devise a protocol for administering specific PRN (“as required”) medication has now been dealt with. Health Action Plans are now also being developed. 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.
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 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 Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 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): EVIDENCE: Key Standard 2 was assessed at the last inspection and met in full. There have been no admissions since that time. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 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 Residents’ care plans include their assessed needs, but require further development so that detail is expanded and individuals’ goals are also reflected appropriately. Residents are supported to take risks in a responsible manner so as to enhance their independence, but risk assessments continue to be in need of development. EVIDENCE: Key Standards 6, 7 and 9 were assessed at the last inspection. Standard 7 was met in full, and Standards 6 and 9 were partially met. A requirement was made at the last inspection that care plans be developed further. In particular, this included expanding detail so that the reader could know exactly how support should be given. It was also required that individual plans should include targets with outcomes that can be measured. This was discussed with the Manager during the visit. There is evidence that work has gone on to develop people’s care plans, but this remains a work in progress. It was noted in particular that one resident’s plan included evidence of some very positive efforts to develop the use of person-centred approaches. Good work
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 10 already done now needs to be built upon and the plans for all the people living in the house brought up to the standard required. (See Standard 37 also.) Similarly, the development of risk assessments required at the last inspection continues as a work in progress. There is evidence to demonstrate that due consideration is given to supporting residents to take risks in a responsible manner, so as to encourage their independence. However, risk assessments need to reflect this accurately, and information gained from the risk assessment process included in individual care plans appropriately. Work also needs to continue on the development of residents’ detailed communication guidelines. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 Residents are able to take part in appropriate activities and to access the local community. However, there is a continuing need to improve the standard of activity recording and to review the range and quality of opportunities available. EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the last inspection. Standards 15, 16 and 17 were met in full, and Standards 12 and 13 were partially met. A requirement was made at the time of the last inspection that the opportunities for residents to participate in the life of their local community and to pursue valued activities should be reviewed. It was further noted that there is a good tool in place for recording activities. At present, it is difficult to assess the effectiveness of individuals’ activity programmes, as the recording is somewhat limited. The staff team needs to be fully aware of how important it is that recording is of a good standard. It must provide sufficient detail to support proper analysis
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 12 and inform future planning. The tools to do this are in place, and it may be that some training is required to ensure that people use these appropriately. The opportunity to pursue valued activities is a prime indicator of the quality of life enjoyed by people in care, and this should not be underestimated. It is important that staff record what people do, and also what opportunities are offered but declined. Activities should have an identified purpose, and should be clearly linked to individuals’ assessments of need, care plans and agreed goals. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Members of the care team meet residents’ healthcare needs appropriately. General practice with regard to dealing with medicines in the Home is satisfactory. EVIDENCE: Key Standards 18, 19 and 20 were assessed at the last inspection. Standard 18 was met in full, and Standards 19 and 20 were partially met. As previously reported, people living in the house and staff looking after them appear to be relaxed and at ease in each other’s company. Support is given with respect and in a warm and friendly manner. Residents’ personal attire and grooming provided evidence that basic personal care is given to a very good standard. Requirements made at the last inspection with regard to the management of one resident’s epilepsy, and to produce a protocol for administering PRN (“as required”) medication, have now been met. There is also evidence of development of Health Action Plans, and this work needs to be continued for all the residents. The health of one resident in particular continues to give rise to concerns, but appropriate medical help has been sought, and his condition is being closely monitored.
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 22 and 23 were assessed at the last inspection, and met in full. Wood Lane, 135 DS0000016881.V285850.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): 24, 25, 27, 28, 30 Residents enjoy the benefit of living in a house that is homely, safe and comfortable. People’s bedrooms suit their needs and lifestyles, and shared spaces in the house complement individuals’ rooms, but some items are in need of attention. Toilets and bathrooms provide sufficient privacy and meet residents’ needs, but some repairs are required. The home is kept clean and tidy, and a good standard of hygiene maintained. EVIDENCE: As previously reported, the house at 135 Wood Lane is a pleasant domestic scale property, providing the residents with a comfortable home environment. Standards of furnishing and decoration are generally good, but some areas are now in need of attention. Staff keep the house clean and tidy, and maintain a good standard of hygiene. The downstairs bedroom has been decorated. Communal spaces, notably the hall, stairs and landing are showing signs of wear and tear and would benefit from refurbishment. Plasterwork on the wall by the laundry should be repaired.
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 16 Residents’ bedrooms are individual in style, with personal effects and possessions in evidence. The carpet in the shared room should be replaced. It was noted that the window catches in the upstairs bathroom are faulty and should be replaced. The seat on the toilet in this room was also loose, and an immediate requirement was made to secure this, so as to prevent any accidents. It was also noted that there was a fence panel missing in the back garden, and this should be replaced. It should also be acknowledged that some of these issues have been reported to the Organisation’s maintenance team and may already be “in hand”. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 17 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, 36 A training and development plan is required in order to assess fully the qualifications, competence and training needs of the staff team. The team needs to be brought up to complement. General recruitment practice promotes residents’ protection, but this must be supported by required documentation. Arrangements for formal supervision need to improve. EVIDENCE: A previous requirement to provide an up to date training and development plan for the staff team remains outstanding. This must now be completed without delay. The plan should show, for each member of staff, training completed and qualifications gained. It should highlight any gaps, including refreshers, and indicate when outstanding training is scheduled, and who is to deliver it. The Manager advised that one member of staff was qualified to NVQ level 3, another to NVQ level 2, and another held an HND in Social Care. Eight members of the care team are said to have completed Learning Disability Awards Framework (LDAF) training, and another three enrolled. Sample checking of staff files revealed that documentation required by regulation (Care Homes Regulations 2001) is not in place for all staff, and this must be addressed. Recruitment is co-ordinated from a central location, and
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 18 systems are in place to ensure that appropriate procedures are followed, but this must be supported by the documents stipulated, which should be available for inspection. Staff numbers have improved since the last inspection, in particular to provide 1:1 support to one resident. Waking night time cover is now also being provided, in accordance with individual assessed need. Recruitment is ongoing, and the Manager advised that there are currently 30 hours vacant. These are being covered by regular staff or by bank staff familiar with the residents (where possible) so as to promote continuity of care. The Manager advised that he is seeking to delegate some responsibility for staff supervision to senior members of the care team. Records were not available to enable an accurate assessment of the arrangements for formal supervision. Action must now be taken to ensure that all members of staff receive formal supervision at least six times in any twelve-month period (pro rata for part-time staff), and that a written record is kept of each meeting. A staff group meeting was held on the day of the inspection visit. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 19 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, 41, 42 The general running of the home could be improved by ensuring that the Manager has sufficient “dedicated” time to fulfil his managerial responsibilities. It is difficult to assess how residents’ views underpin self-monitoring, review and development in the home. Residents’ rights and best interests are generally safeguarded by record keeping procedures, but some aspects of practice need to improve. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: The Registered Manager is a qualified nurse for people with learning disabilities (RNMH). He is working towards attaining the Registered Manager’s Award (RMA) and advised that he has two units left to complete. It should be noted that obtaining the RMA by April 2005 was a condition of registration, and that this is therefore overdue. However, it must be acknowledged that problems
Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 20 with staffing levels, and issues directly related to providing support to residents who have complex and high level support needs, have influenced priorities in this regard. The Manager is also to begin work towards attaining A1/2 shortly, so that he can support staff working towards NVQ qualifications. The Registered Provider must review the current arrangements in the Home, and ensure that the Manager has sufficient dedicated time (“off rota”) to fulfil his managerial responsibilities. This should take account of the issues highlighted in this report, notably the need for care plan development, staff supervision (both formal and informal) and training, and the complexity of the needs of people living in the house. Reports of visits required under Regulation 26 (Care Homes Regulations 2001) have been received by CSCI, but it should be noted that these visits (which must be unannounced) should take place at least once a month, and a written report produced. The Registered Provider should produce a report of quality assurance and monitoring activity. The outcome for this Standard (39) seeks to ensure that the views of people using the service underpin all selfmonitoring, review and development by the home, and the report should reflect this. It was noted that entries in the staff communication book contained personal information relating to named residents. This practice does not comply with current data protection legislation. Such information should only be retained on individuals’ personal records. Entries in the communication book should “signpost” the reader to the appropriate location – e.g. “see notes dated 02.03.06 in AB’s file”. Safety records were sample checked. The fire alarm and emergency lighting systems have been checked regularly, and records completed as required. The systems have also been serviced. It was noted that the workplace fire risk assessment is now due for review. Records relating to fire training should be distinct from those relating to fire evacuation drills, which should show the names of all those taking part. Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 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 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 2 X 2 X 2 3 X Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1-2) Requirement Timescale for action 31/05/06 2. YA9 15 (1-2) 13 (4) 3. YA12YA13 16 (2m-n) 4. YA25 16 (2c) Care plans must be developed further to include sufficient detail so that the reader will know exactly how support should be given. Plans should also include goals with measurable outcomes, which should be evaluated when plans are reviewed. Individuals’ communication guidelines should also be expanded and developed further. Develop risk assessments to 31/05/06 ensure that control measures are included in care plans, and cross-reference risk assessments to the plan(s) to which they relate, and vice versa. Review opportunities for 31/05/06 residents to participate in the life of the local community and to pursue valued activities. Expand detail of activity recording, which should indicate the purpose of activities undertaken and demonstrate clear links to individuals’ care plans and agreed goals. The carpet in the shared 31/05/06 bedroom should be replaced
DS0000016881.V285850.R01.S.doc Version 5.1 Wood Lane, 135 Page 23 5. 6. YA27 YA27 23 (2) 13 (4c) 7. YA34 19 Sch 2 Sch 4 18 (1a) 8. YA35 9. YA36 18 (2) 10. YA37 8 11. YA39 24 26 12. YA41 17 13. 14. YA42 YA42 13 (4) 13 (4) Window catches in the bathroom should be replaced. The toilet seat in the upstairs bathroom should be made secure. (Immediate requirement) Ensure that all documents required by regulation (Care Homes Regulations 2001) are maintained for each person working in the home. Produce a staff training and development assessment and plan, as indicated in the main body of this report. Outstanding since 31/12/05. Ensure that each member of staff receives formal supervision at least six times in any 12month period (pro rata for parttime staff), and that a written record is kept of each meeting. Ensure that the Registered Manager has sufficient time specifically dedicated to enable him to fulfil his managerial duties. Ensure that visits and reports required under Regulation 26 (Care Homes Regulations 2001) are completed at least once every month. Produce a report of quality assurance and monitoring activity for the home, showing how the views of residents have been taken into account. Ensure that messages written in the staff communication book do not contain personal information relating to named residents. Messages should direct the reader to the personal records of the individual concerned. Review the home’s workplace fire risk assessment. Ensure that records of fire drills show the names of all those
DS0000016881.V285850.R01.S.doc 30/04/06 03/03/06 31/05/06 30/04/06 31/05/06 30/04/06 31/05/06 30/04/06 30/04/06 30/04/06
Page 24 Wood Lane, 135 Version 5.1 taking part. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA23 YA42 Good Practice Recommendations Cross-reference the adult protection policy and procedures to local multi-agency guidelines. (Not assessed) Mark the counterfoil stubs of accident book reports with the date and the initials of the person involved. (Not assessed) Wood Lane, 135 DS0000016881.V285850.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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