Inspection on 20/06/05 for 15 Woodville Road

This inspection was carried out on 20th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

15 Woodville Road 04/12/06

15 Woodville Road 28/02/06

15 Woodville Road 04/02/05

15 Woodville Road 02/09/04

15 Woodville Road 05/03/04

15 Woodville Road 21/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Woodville Road, 15 Harborne Birmingham B17 9AS Lead Inspector Brian Reamsbottom Unannounced 20th June 2005 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 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 Stationary 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. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Woodville Rd 15 Address Harborne Birmingham B17 9AS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 428 2455 0121 602 1427 New Outlook Housing Michelle Louise Dennehy Care Home 5 Category(ies) of Care Home registration, with number of places Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 4.02.05 Brief Description of the Service: Woodville Road is a large traditional house. There is accommodation for five younger adults with a visual impairment and an associated learning disability. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for the service users. Service users are encouraged and supported to maintain links with their families and the local community. The care needs of the service users are monitored and reviewed and action is taken to address any concerns. The home is in Harborne, a residential area of Birmingham. It is in walking distance of shops, pubs, parks, places of worship and public transport. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected unannounced from 13.30 to 16.30. The documentation inspected included the following: Care plans, risk assessments, fire records, medication records, health and safety records, accident book, daily records, complaints and adult protection records, staff personal files and staff training records. Three service users and two members of staff were spoken with. What the service does well: What has improved since the last inspection? Service users continue to be encouraged to have a say in the running of the home. Helping service users to maintain and improve their independence. Helping service users to see themselves as part of the local community. Staff training is on going with the staff team taking part in the training offered enabling them to meet the needs of service users. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 6 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. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 1 and 2 Prospective service users are be able to make an informed decision about the service offered at the home by the Statement of Purpose and the Service User Guide. EVIDENCE: Service users have a summary of the Statement of Purpose and have a Service User Guide. A new service user has been admitted recently. On inspecting the personal file there is a full assessment, which includes the needs and wishes of the service user. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 6 7 and 9 Service users assessed needs and goals are reflected in their individual care plans so that staff know how to support each individual. The care plans must be reviewed as a priority. Risk assessment practices meet the needs of service users living in the home. EVIDENCE: Service user personal files inspected included individual care plans. These included how staff are to support the service user with communication, personal hygiene, daily living skills, behaviour, health, diet, leisure activities, medication, social activities and personal safety. Personal care is given behind closed doors. The care plans had not been reviewed within the last twelve months. The deputy manager was asked how often the care plans are reviewed the response was every twelve months. It was discussed that the care plans must be reviewed twice a year or, as service needs change. Behaviour guidelines in the plans were last reviewed June 2003. These must be reviewed to enable the staff team meet the needs of service users. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 10 By observation and speaking with two service users it was clear that they exercise their right to making decisions in their daily life. The staff members on duty were responsive to the wishes of service users. Risk assessments were in place for service users. They include assessments for the garden, preparing meals and snacks, mobility, activities in and out of the home, the bath, personal hygiene and fire. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 12 13 15 16 and 17 Service users are part of the local community and participate in appropriate leisure activities. Arrangements are in place to support service users to have appropriate family relationships. Service users choose what they eat and enjoy their meals. Food is nutritious and meets dietary needs. EVIDENCE: Two service users attend a local day centre were they take part in various activities, for example, cake making and music sessions. Service users have weekly sheets showing the activities in the home and away from the home, for example, music therapy, swimming, massage, and aromatherapy. However, on inspecting the weekly activity sheet they did not reflect the activities in the care plans and daily records. The deputy manager agreed that they required up dating. Two service users had individual aromatherapy in their own bedrooms. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 12 Service users access local shops, cinema, social clubs and library. Visits are made to the local pub for a drink and a meal. Service users have good contact with their families, by visits, letters, cards and telephone calls. The manager and staff are actively involved in maintaining links with service users and family. Records of contact with families are kept in the service users personal files. The menus showed that the food is varied, wholesome and nutritious. Records are kept of the actual food eaten by service users. Two service users said that they enjoy the food on offer and that they have plenty choice. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 19 and 20 Systems are in place to ensure that service users receive the care they need. The medication management is good ensuring service users receive medication as prescribed. EVIDENCE: Relevant professionals are involved in the support of service users, for example, visits to GPs, and Dentists. The Chiropodist visits the home. The home is working on introducing Health Action Plans for each service user. They are looking at the best way to include the involvement of service users in their Health Action Plan. In one service user’s personal file there was a weight chart showing that weights were recorded monthly, however, the last recorded entry was 31.08.04. These records must be accurately maintained to assist in the health and wellbeing of service users. The management of medication is good. A Monitored Dosage System (MDS) is in place. There are protocols for ‘as required’ (PRN) medication. A Pharmacist from the supplier of the MDS visits the home on a regular basis giving support in the safe administration and storage of medicines. Medication is safely stored in an appropriate cabinet. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 22 and 23 The complaints and adult protection procedures available ensure that service users are protected from harm. EVIDENCE: The and The and home has a complaints procedure in place it is also available in large print audiotape, this is to be commended. complaint procedure inspection must have the NCSC changed to the CSCI have the address of the Ombudsman. The home states that they have received no complaints since the last inspection. The adult protection procedures in place reflect the spirit of Birmingham’s Multi-Agency Guidelines. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 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 standard(s) 24 and 30 The home was clean and well maintained it provides service users with a safe, homely and comfortable environment. EVIDENCE: The home was warm, clean and hygienic. It is decorated and furnished to a good standard meeting the needs of service users. The service users live in a relaxed and comfortable environment. Work has now begun on the extension to the home. It will improve facilities, to include a new kitchen, laundry, office and the installation of a shaft lift. Service users will be going on holiday when the main work begins. On their return from holiday the organisation is renting an appropriate property for the duration of the work. The service users are excited and are looking forward to seeing the completed work. A full tour of the home was not undertaken at this visit. Policies and procedures for the control of infection are in place. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 36 An effective staff team supports service users. Service users are protected by the home’s robust recruitment practices. Staff receive the appropriate training to meet residents individual and joint needs. Staff are supported and regularly supervised which benefits the residents. EVIDENCE: The staff files inspected included all the information and documentation required in Schedule 2 of the Regulations. The staff group have had induction training and have done all statutory training, for example, Moving and Handling, First Aid and Basic Food Hygiene. The staff group have completed the Learning Disability Award Framework (LDAF) training. Two staff members are doing NVQ level 2 training they said that they are about to finish the course. The staff members said that they have found the training beneficial enabling them meet the individual and joint needs of service users. The staff team have individual supervision sessions at least six times a year. Minimum staffing levels are being maintained. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home is well managed ensuring the health, safety and welfare of service users are promoted and protected. EVIDENCE: The home is involved in producing a quality assurance monitoring system to include the views of service users, family, friends and involved professionals. There is an annual development available if required. The home has a range of policies, procedures and systems in place to comply with the requirements of health and safety legislation. Risk assessments are in place for the premises, fire, food, hygiene and service users. Records of testing of electrical, fire and gas equipment were seen to be in order. Water and fridge/freezer temperatures are tested on a regular basis and a record kept. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 18 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Woodville Road, 15 Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 19 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. 2. 3. Standard YA 6 YA 6 YA 19 Regulation 15.(2)(b) 15.(2)(b) 12 (1) (a) (2) Requirement Care plans must be reviewed at laest twice a year or as the needs of service usere change. Behaviour guidelines must be reviewed. Each service user must have a Health Action Plan in line with Valuing People. A Health Action Plan is a perosnal plan about what a person with a learning disability can do to be healthy. It lists any help people might need to do those things. It helps to make sure people get the services and support they need to be healthy. The manager must be qualified to NVQ level 4 in management and care. There is a continuous self monitoring, using an objective, consistently obtained and reviewed and variable method and involving service users and an internal audit takes place at least annually. Timescale for action 31.07.05 31.07.05 31.08.05 4. 5. YA 37 YA 39 9.(2)(i) 24.(1)(a) (b)(2)(3) 31.12.05 31.08.05 Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 20 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 YA24 YA30 Good Practice Recommendations Consideration should be given to providing office space. The manager should make alternative access to the laundry. Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Birmingham and Solihull Local 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 Woodville Road, 15 E54_S16806_WoodvilleRd_V234425_100605 Stage 4.doc Version 1.30 Page 22 - 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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