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Inspection on 09/01/07 for Woodridge Road

Also see our care home review for Woodridge Road for more information

This inspection was carried out on 9th January 2007.

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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff were welcoming, caring and friendly. The women all have their own bedrooms, and they all contain things that are important for each person. Some of the women were seen to regularly access their room during the inspection, and they appeared comfortable and relaxed. The range of food available was interesting, and varied and included fresh fruit and vegetables. The women were seen to enjoy their food, and it formed an important part of their day.

What has improved since the last inspection?

Progress had been made on previous requirements indicating compliance with the regulations and improvements in the quality of life for service users. Improvements have been made to service users care plans so that these give good clear information about how service users needs should be met by staff.A new carpet has been fitted in the lounge and a new sofa and chairs provided so that the home is nicer and cleaner for service users. Staff have received training in epilepsy, objects of reference and ageing so they have a better understanding of the needs of the people they support.

What the care home could do better:

Some improvements have been made to managing the impact of service users behaviour on other people living and working in the home, however further progress must be made so that people are not put at risk and feel safe in their own Home. Reassessments of peoples needs are taking place. These must address that one of the persons needs fall outside of the registration of the Home. The provider must tell CSCI what they will do to address this so that service users individual needs are met. The poor physical standards in the kitchen have the potential to put service users at risk, as the break down of work surfaces is now difficult to keep clean and free from bacterial contamination. The laundry must be reorganised so that clean and dirty clothes are handled separately, mops are stored appropriately and the ventilation fan is cleaned and the risk of cross infection well managed so service users are not put at risk. Although the Home is a bungalow access for people who use a wheelchair is limited. Service users who use a wheelchair cannot access the laundry and have only limited access to the kitchen. This must be looked at as it limits opportunities for service users to develop their independent living skills. The amount of staff on duty during the day and night is not enough to meet service users complex needs. This must be looked at so service users are safe in their home and receive the support to do the things they would like to do. Any agency or bank staff that are working in the home must provide the manager with evidence of the training they have done and that they have been checked as safe to work with vulnerable people.

CARE HOME ADULTS 18-65 Woodridge Road 6a Woodridge Road Aston Birmingham West Midlands B6 6LN Lead Inspector Donna Ahern Unannounced Inspection 9 January 2007 10:30 th Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodridge Road Address 6a Woodridge Road Aston Birmingham West Midlands B6 6LN 0121 240 4480 F/P 0121 240 4480 maggieoakley@southbirminghampct.nhs.uk www.midlandheart.org.uk Focus Futures Ltd South Birmingham Primary Care Trust Mrs Margaret Judith Oakley Care Home 4 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) Category(ies) of Learning disability (4) registration, with number of places Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years. A maximum of 4 service users may be accommodated for reasons of learning disability Two named service users over the age of 65 years can be accommodated providing the home can demonstrate it can meet their needs and this is subject to periodic review. 1st June 2006 Date of last inspection Brief Description of the Service: 6A Woodridge is a modern bungalow, situated in a quiet cul-de-sac in Aston. The home is registered for four adults with a learning disability. At the time of inspection the residents were all female, two of the service users were over 65. One of the persons needs fall outside of the Homes conditions of registration. The home is close to main roads that are served by public transport, enabling travel into the city centre, and the One Stop Shopping centre. The home is purpose built. There are four single bedrooms, a communal assisted bathroom, shower room, laundry, kitchen, dining room and lounge. Access to the laundry and kitchen is poor for people who use a wheelchair and limit their opportunity to develop independent living skills. There is no office and this has an impact on privacy and dignity, as there is no private place for meetings or phone calls to take place. There is off road parking for approximately three cars. The home has a tidy garden at the rear, which has facilities for service users to sit, out, and undertake gardening. The home has a very stable staff team, with few vacancies. The home has a registered manager. The current fee level is £1582.07 per week. Additional charges are made for toiletries and activities. The charge to service users for the use of the homes vehicle and what the cost will be was still under review. The CSCI inspection report was available in the home for people to read. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved two inspectors and took place over one day lasting nine hours. This was the homes second key inspection for the inspection year 2006-2007. During the fieldwork the inspector met all service users, observed the opportunities and support provided to service users, looked at the premises, and read records about care, staffing, and health and safety. Conversations with service users were limited due to peoples communication needs. Comments in the report are based on observations of care given during the fieldwork and information gained from reading records relating to peoples care. The inspector spoke to the manager and spoke to four staff informally. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. A pre inspection questionnaire was completed by the manager and returned to CSCI. Information from the questionnaire was used to help complete this report. What the service does well: What has improved since the last inspection? Progress had been made on previous requirements indicating compliance with the regulations and improvements in the quality of life for service users. Improvements have been made to service users care plans so that these give good clear information about how service users needs should be met by staff. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 6 A new carpet has been fitted in the lounge and a new sofa and chairs provided so that the home is nicer and cleaner for service users. Staff have received training in epilepsy, objects of reference and ageing so they have a better understanding of the needs of the people they support. 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. The summary of this inspection report can be made available in other formats on request. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have information to enable them to make an informed choice about whether or not they want to live in the home. EVIDENCE: The Home has a stable service user group there have been no new admissions to the Home for more than seven years. Therefore it was not possible to assess standard 2 relating to assessment of service users before they move into the Home. The provider has an assessment procedure that if followed should ensure that prospective service users needs would be assessed prior to admission. The statement of purpose and service user guide were looked at and describe the services and facilities provided. The manager was in the process of developing the service user guide further so it is more accessible to the people who live at Woodridge Road. The care providers who are South Birmingham Primary Care Trust have given notice to Birmingham City Council. New care providers are currently being sought. Service users have been informed of this and there were letters on people’s files informing them of the changes. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further development of is required so that staff have the information they need to enable them to meet service users assessed needs and goals. Risk assessments must be further developed so that sufficient arrangements are in place to ensure the risks service users face are well managed. EVIDENCE: Progress had been made on implementing a care plan format and two peoples care plans were looked at. The individual plans had details of how staff should support people with their health, communication, personal care and social needs. It contained clear information about the person’s likes and dislikes and how to maintain contact with their relatives and friends. Information was easy to find and follow. It was written in an easy read style and pictures and photographs were used so making them easier to understand and more accessible to service users. Individual goals have been identified; these are Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 10 personal aims that the service user wants to achieve either personally or with support from care staff. Whilst it was clear that some of the goals had been achieved like purchasing a new wheelchair for one person, it was not always clear what must be done to achieve the goals or if they are still relevant for the person. The manager said that the monthly summaries which are completed by the keyworker with the service user, would start to review people’s goals and staff will start to add this information to the care plan so that it is clear how service users will be enabled to achieve these. It is essential for personal growth and development that opportunities to maintain independent living skills are provided even when service users have limited ability to do so. People’s care plans only briefly refer to personal development. Observations during the fieldwork indicated that service users personal development is promoted such as making drinks, taking their washing to the laundry; this therefore should be reflected in their care plan. A monthly review system of the care plan is in place ensuring that the support service users require from staff to meet their needs is kept up to date. A number of risk assessments were available and a review sheet attached indicated that they are reviewed monthly. The review of risk assessments must be developed further so that if an incident has occurred, there must be evidence of cross-referencing this to the risk assessment. The control measures in place must be reviewed and any changes made. Risk assessments are required to be implemented in additional areas including support to residents during the night and the use of wheelchair so that the risk service users face are planned for. It is advised that care plans cross-reference to risk assessments so that staff know when additional supporting information needs to be read to appropriately support the service user. As raised in previous inspection reports there is no private space to undertake meetings, reviews or private discussions. Which are essential to the running of a care home. All these activities take place in communal areas or in people’s bedrooms. These arrangements must be reviewed so that the confidentiality of each person is respected and upheld. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s):12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain contact with people important to them so they maintain personal relationships. The range of activities available requires some further development so that service users benefit from opportunities that meet their individual needs. EVIDENCE: On the day of the fieldwork two service users were supported to go shopping and out for lunch. Two service users relaxed at home listening to music and the television. In the afternoon service users spent time in their own room, listened to music and enjoyed a sing a long, played dominos looked at books and one service user enjoyed a foot spa and massage. Interactions from staff Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 12 were generally good. Staff sat and engaged on a one to one with service users and responded appropriately to requests that were made. Staff said and care plans indicated that each person spiritual and cultural needs had been explored. One service user has indicated that they want to continue to practice their faith and attend a weekly church service. There was really good information on their care plan about how the person should be fully supported to meet this need. Weekly activities include music therapy, white space which is a sensory session, shopping and a disco on a Saturday for some of the service users. Occasional trips out to the cinema and bowling are also planned. The Home has the use of a car, but only have two staff who are approved drivers, which limits opportunities to use the car. Taxies and local transport are also used. Calendar activity planners were just being completed so each service user will have their own and any planned activities will be put on the calendar. The manager said that new social and leisure opportunities are being explored for each person so they engage in a range of appropriate activities according to their particular interest and individual needs. A place at a day centre for people with head injuries was being explored for one person so that they have the opportunity to meet and socialise with people with similar needs. Service users are well supported to maintain contact with relatives and friends where personal circumstances allow. It is really positive that a referral has been made for an advocate for one person. This is someone who will help to speak up for the person and make sure that things are done in their best interest and are independent of the staff in the home. Service users opportunities to take part in activities impact on other service users due to staff availability. This is raised again under the staffing standards and must be reviewed. Records seen of service users response to activities really varied some where well written and gave clear information others lacked detail of what the person had done and if they had enjoyed the activity. Service users have limited verbal communication. It is important that this information is recorded so that it can be used for future planning and monitoring. During the visit staff interacted well with service users conversations were directed towards service users and staff engaged in one to one activities. Menus seen indicated that a range of nutritious and culturally appropriate food is provided. Meals served on the day were well prepared. Support given to people whom require assistance was given in an unrushed way. Specialist cutlery was available as stated on peoples care plan. The manager has referred all service users to the dietician service so that advice can be sought on whether the menus are healthy and balanced and meet the different needs of Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 13 service users as two of the people are elderly and one person has limited mobility. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s):18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements in place for the management of health care must be improved so that potential risks and health problems can be identified and dealt with effectively. Medication is generally well managed ensuring that service users receive their medication as prescribed. EVIDENCE: Service user individual plans seen had details of people’s personal care routines and preferences. Service users were observed receiving good support with their personal care. Service users were appropriately dressed in accordance to their age and culture. Health care notes looked at indicate that service users are supported to attend routine G.P, dentist, and optician appointments. There had been some difficulty Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 15 with the chiropody service usually provided and service users required prompt support with this as peoples nails required cutting. The manager agreed to address this immediately. Records seen and discussions with staff indicated that health professionals are involved in the care of individuals. These include the Community Nurse, Psychiatrists, Continence Nurse, Physiotherapist and Speech and Language Therapy. A care plan in respect of the support given to a service user at mealtime and when a drink should be given must be updated to reflect current professional advice and the current practice seen at the time of the fieldwork. Health Action plans have been implemented. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The recordings of outcomes of appointments were generally satisfactory so that health needs and any follow up action required could be monitored and actioned. The manager said that staff are to receive support from health care facilitators to develop the Health Action Plans so that they are produced in a more user friendly format accessible and more meaningful to service users. The monitoring of peoples weight is important for the early detection of other health problems or complications. Service users weight monitoring recordings were infrequent. The manager said that service users now attended the weight clinic so that accurate monitoring could take place. The support service users require at night from waking night staff must be risk assessed and documented on their care plan so that any support given from night staff is in accordance with their assessed needs. The risk assessment in place for one person who uses a wheelchair but refuses the use of lap belt must be explored further with the person. The manager said a referral has been made to reassess them for a new wheelchair. The chair must be used in accordance with manufactures guidelines and the service users safety must be paramount when accessing the community. One of the service users has an acquired brain injury and their needs fall outside of the homes category of registration. Strategies for managing and supporting people with such needs require specific training and understanding of people with acquired brain injury. This has not been provided to the staff team. Reassessments of peoples needs is currently taking place by Social Care and Health and these concerns should be addressed so that the person receives the care and support that meets their assessed needs. All four service users require support from staff to take their medication. The medication is stored in a secured metal wall mounted cupboard in a small Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 16 storage area off the dining room. Medication is provided to the Home using the monitored dosage system. At the front of each service users Medication Administration Record (MAR) there is a photograph of the person detailing the person’s personal details so that it is clear to staff whom to give the medication to. There is also advice about how the person likes to receive the medication. Where service users are prescribed as required (PRN) medication protocols are in place stating how much, why and when this medication should be given. The medication administration records (MAR) cross-referenced with the blister packs indicating medication had been given as prescribed. A record of non blister pack medication must be kept so that an audit trail of all medication received and administered can be accounted for. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s):22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient systems in place to ensure that concerns about the service would be raised and addressed. Arrangements are not sufficient to ensure that service users are always protected from abuse. EVIDENCE: The complaints procedure included all the required information to enable service users or their representatives to make a complaint to the organisation. The procedure was available in an easy read format using pictures so it was easier for service users to understand. A summary of the procedure was on display in the hallway so it was available to visitors to the Home. The complaint log seen and the manager confirmed that no complaints have been received in the last twelve months. CSCI had not received any complaints about this home. Two service users financial records were looked at. Service users money is kept securely and receipts were available of purchases. Service users financial records were checked and cross-referenced with the amount in their individual purse. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 18 The previous CSCI inspection report raised concern about the physical and emotional welfare of the service users and the risks they pose to each other. A multi-disciplinary review had taken place to discuss the concerns. The manager and staff reported that there has been some reduction in behaviour as staff try to distract and work through some of the verbally abusive comments. The psychologist is currently working with staff and analysing service users behaviour so that advice and guidelines can also be developed. Observations at the time of the fieldwork indicate that the impact of service users behaviour on their peers is still a concern and further input is required so that service users are safe in their own home. Reviews of all the people who live at Woodbridge were in the process of taking place and these concerns will need to be explored. Staff have received training June 2006 in adult protection and the prevention of abuse. The Protecting Vulnerable Persons Policy and the Multi-Agency Guidelines, which are produced in conjunction with Social Care and Health were available in the Home and provide information for staff to follow if a protection matter, occurred. All staff must receive training in managing confrontation so they have the knowledge and skills to manage the difficult situations that arise in the Home. It was advised that a log of regulation 37 reports is kept so that there is a clear audit trail of information to assist with the analysing of incidents. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to the physical standards so that it is clean, safe and hygienic for service users. EVIDENCE: Some improvements have been made to the physical standards of the home since the last inspection. A new carpet have been fitted in the lounge and a new suite provided, making the environment a lot nicer and more hygienic for service users. Previous reports have raised concern about the kitchen. It is very worn the surface of the doors and inside cupboards have started to break down, and cannot be cleaned to the required standard presenting the potential for an infection control risk. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 20 Service users have individual bedrooms. Two service users showed the inspector their room. These were very personalised and service users had been supported to display personal items. There were pictures and photographs on the walls, which service users indicated, were very important to them. One service user had astro-ceiling decorations. These are images put onto the ceiling to light up in the dark. The service user had also purchased some additional free standing and wall lights. Cushions and throws made the rooms comfortable and cosy. The service user seemed comfortable and relaxed in their room but was unable verbally to express their view. The requirement to decorate two service users bedrooms remains outstanding from previous reports. The laundry arrangements require review to control the spread of infection. There must be designated areas for storing laundry so that soiled clothes is not stored with clean clothes. The arrangements for the storage of mops in this area must also be looked at, as mops for different areas that were colour coded were stored on top of each other this poses a risk to the spread of infection. The cupboard in the laundry requires a lock so that items that need to be secured under the C.O.S.H.H (control of substances hazardous to health regulations) regulations can be safely stored and easily accessible when needed. The extractor fan required servicing and cleaning so that it is safe working order and provides ventilation in what is a very small-restricted laundry room. The general standard of cleanliness in other areas of the home was satisfactory. Cleaning schedules are in place so that a hygienic environment is maintained for all service users. Food hygiene practice was satisfactory. Food stored in the fridge was signed and dated. The staff team had commenced a food safety training pack, which should ensure that food safety is in line with required standards and protects service users. Although the Home is a bungalow access is restrictive for people who use a wheelchair. One of the current service users has a physical disability and uses a wheelchair to mobilize in the Home. They are unable to fully access the laundry and can only take their clothes to the laundry doorway. This prevents them from maintaining or developing their independent skills. The kitchen is also restrictive for this person as they are unable to safely access the work surface areas or fully use any of the equipment, again restricting opportunities for this person. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not adequate to meet the social and recreational needs of the people living at the Home. EVIDENCE: Staffing levels are three on the morning shift and two staff on in the afternoon/ evening and one member of staff is on a waking night shift. Rotas seen and discussions with the manager identified that extra staff will be put on shift when possible to raise the number of staff to three in the afternoon and for specific planned events up to four staff may be on duty. Observations at the time of the fieldwork indicate that minimum staffing levels should be three so that service users needs can be met. It is unacceptable at key times that staffing levels are dropping to two. The impact of service users behaviour on other service users requires staff to be supervising at all times. All service users require one to one support to meet their personal care needs. Staff are responsible for all cleaning and cooking tasks, which takes up one staff members time for a large part of each shift. Three service users are one Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 22 to one support and one person requires two to one support when accessing the community or taking part in activities. At night records indicate that service users require a lot of staff support and some service users get up very early or have unsettled sleep patterns and require support and supervision. This presents difficulties when there is only one person on duty. Current staffing levels across the day and night must therefore be reviewed so that adequate staff are on duty at all times to meet service users individual needs. Service user were unable to tell the inspector their views about the staff but from observations during the fieldwork the inspector concluded that service user were very comfortable and relaxed with the staff on duty throughout the fieldwork visit. The recruitment records for two staff were sampled. Checks of the person’s suitability to work in the home had been made; including satisfactory Criminal Records Bureau checks, completed application form and proof of identification. Profiles detailing what training staff have completed, their experience and CRB detail are required for all bank and agency staff working in the home. The manager can then ensure that the balance of staff on each shift is appropriate to meet service users needs and that staff are safe to work in the Home. It is really positive that all staff have achieved either NVQ level 2 or 3 which ensures all staff have completed the minimum training required to meet service users needs. Training recently completed and scheduled for the next few months included both mandatory and those reflective of service users needs including epilepsy, elderly care and objects of reference. Training for all staff is required on minimizing confrontation and training specific to supporting people with acquired brain injury so they have the required skills and training to meet the specific needs of all service users. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements in place generally ensure that service users health, safety and welfare is promoted. Resident’s views do not underpin all self-monitoring, review and development of the Home. EVIDENCE: Throughout the inspection the manager was open and welcoming to the inspection process. She has been the registered manager for three years and has completed NVQ level 4 and is in the process of completing the registered managers award and a foundation degree. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 24 The relationships between the manager, service users and staff were good. Progress had been made on previous requirements. A number of health and safety records were looked at. The manager had also completed the pre inspection questionnaire to confirm dates of health and safety checks. Fire safety records showed that the fire alarm system is tested and serviced as required so that it is kept in a safe working condition. Fire drills were being carried out every six months so that service users and staff have the opportunity to practice safe evacuation in the event of an emergency. The manager agreed to develop the fire procedure further so that it contained specific information to the home including the full address details that should be given to West Midland Fire Service in the event of a fire and clearer information about fire evacuation points so service users and staff know what to do. Water temperature checks are completed weekly to prevent the risk of scalding. The records need to show what action staff have taken to safe guard service users when recordings above the required temperature of 43degrees are noted. Certificates were in place, which showed that electrical appliances, gas and bathing equipment had been tested and serviced for the protection of service users. Representatives from both registered providers (South Birmingham PCT and Focus Futures) do unannounced visits to the home to check and comment on the standards of care and the environment. The manager has also produced an improvement plan. South Birmingham PCT has developed a draft quality audit system. This stated that audits will be carried out at weekends, night and days and will look at medication, record keeping and complaints. It also says that people will a learning disability will assist with carrying out audits. There was no evidence that these audits have yet taken place. The quality audit system must be implemented so that service users views are sought and underpin all self-monitoring, review and future development of the Home. As raised under Concerns, Complaint and Protection section of the report, further action is required so that service users are safe in their own Home and protected from abuse. Risk assessments were in place for the premises, food and staff to ensure safe practice is promoted for service users and staff. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 25 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 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 26 CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 2 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 2 X X 2 3 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 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 YA6 Regulation 15(1) Requirement Service users plans must evidence their aspirations and goals and how these are to be met. Care plans must reflect how service users are supported to be independent and develop independent living skills. Unmet from last two inspections. Risk assessments that underpin risks service users undertake and are exposed to must be developed. The review of risk assessments must be developed so that there is evidence the control measures in place are still appropriate. The home-owner must provide an action plan with timescales detailing how adequate space for confidential meetings and conversations to take place will be provided Opportunities for activities Timescale for action 31/03/07 2 YA6 YA7 15 (1) (20 31/03/07 3. YA9 13(4)(a-c) 28/02/07 4 YA9 13 (4) (a-c) 28/02/07 5. YA10 23(1)(a) 12(4)(a) 28/02/07 6 YA12 16 (m, n) 31/03/07 Page 28 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 YA13 7 YA18 13 (4) 16 (i) 12 (1) (a) 13 (4) 8 YA18 9 10 11 12 YA19 YA19 YA19 YA19 12(1)(a) 13(1)(b) 12(1)(a) 13 (4) 12 (1) (a-b) 12 (1) (a-b) 13 YA20 13(2) 14 YA23 13(6) 15 YA24 23(2)(b) 3(3) 16 YA26 23(2)(b, d) must be further developed. A service users care plan must be updated to reflect current eating and drinking needs. The support service users require at night from waking night staff must be risk assessed and documented on their care plan. Service users required Chiropody service. Service users weight must be monitored. A risk assessment for the use of a lapbelt must be further developed. A reassessment of a service user who needs fall outside of the homes registration is required. A record of non blister pack medication must be kept so that all medication is auditable. Unmet from last two inspections. The manager must ensure all possible action to keep service users safe from harm, or risk of harm is undertaken. Unmet from last two inspections. Kitchen doors, drawer fronts, and shelves inside cupboards must be maintained in a good state of repair. Two service users bedrooms require decorating. Unmet from the last inspection. 16/01/07 24/01/07 24/01/07 31/01/07 24/01/07 31/03/07 31/01/07 28/02/07 31/03/07 31/03/07 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 29 17 YA29 23 (2) n 18 YA30 16 (2) J 19 20 YA30 YA30 16 (2) J 13 (4) (a-c) 21. YA33 18(1)(a) Access issues in the home must be reviewed for people with a physical disability. The use of the laundry must be reviewed with designated areas for clean and soiled clothes established. The arrangements for the storage of mops must be reviewed. A lock must be provided on the laundry cupboard for the storage of COSHH items. The number of staff provided must be reviewed, and action taken to ensure this safely meets service users needs. Unmet from last inspection. Records detailing training experience and suitability to work in the home must be obtained for all bank and agency staff. Staff training is required on acquired brain injury and managing confrontation. The provider must ensure there is an effective model of Quality assurance in use in the home. A record of action taken when high water temperatures are recorded in service users bedrooms must be actioned. Further development of the fire procedure is required. DS0000016946.V317402.R01.S.doc 31/03/07 31/01/07 16/01/07 16/01/07 28/02/07 22 YA34 7,9,19 schedule 2 31/01/07 23 YA35 18 (1) c (i) 31/03/07 24. YA39 24 31/03/07 25 YA42 13 (4) 16/01/07 26 YA42 23 (4) e 16/01/07 Woodridge Road Version 5.2 Page 30 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. 3. Refer to Standard YA9 YA12 YA18 Good Practice Recommendations It is recommended that risk assessments be stored with care plans or that a clear signpost to them be included in the care notes. It is recommended that the purpose and benefit of activities be established in the service users plan. It is recommended that service users needs regarding their sexuality be further explored and recorded, to ensure these are met. Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Woodridge Road DS0000016946.V317402.R01.S.doc Version 5.2 Page 32 - 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. 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