Care Home: 233 Yardley Fields Road

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What the care home does well What has improved since the last inspection? The four requirements made at the last inspection had been fully addressed and no requirements have been made from this inspection. This indicates that staff view inspections as a positive experience and where action is needed it is dealt with. The topic of activities has been incorporated into the weekly individual meetings to enable staff to arrange for extra requests to be met. Staff have introduced cooking skills into peoples daily lifestyles to encourage their abilities. Staff have received training in equality and diversity to ensure that equal opportunities are complied with within their associated responsibilities. Staff explore peoples needs regarding spiritual preferences. Due to the ageing of people living in the home staff have undertaken training in care of older persons and physiotherapy to assist in their gradual mobility restrictions. The role of the key worker has been further developed to incorporate more responsibilities, which have resulted in enhancement of peoples` life experiences. The system is based on a person centred approach to assessing peoples` needs and preferences. Formal reviews of care plans have been introduced, these are carried out six monthly. This was evidenced during the visit. In the meantime regular reviews of care plans are carried out by staff to ensure that they remain relevant at all times. Peoples identity cards have been improved for when they out in the community in the event that they get lost. The manager has created a sensory room in the area that was originally the garage. This provides a quiet area where people can relax on a one to one basis with a member of staff. The laundry room has been painted. Foot operated bins have been purchased for all communal rooms. One bedroom has been redecorated and furnished; the occupant chose the colour scheme and style of furniture. New easy chairs have been provided for the lounge. What the care home could do better: It is recommended that a document be developed that advises of the fee rate, how the fee rate is calculated and details of the services that are not included in it. This should accompany a copy of the service user guide that is issued to prospective residents of the home. CARE HOME ADULTS 18-65 233 Yardley Fields Road Stechford Birmingham West Midlands B33 8RN Lead Inspector Kath Strong Key Unannounced Inspection 17th January 2008 09:55 233 Yardley Fields Road DS0000071280.V357271.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 233 Yardley Fields Road DS0000071280.V357271.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. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 233 Yardley Fields Road Address Stechford Birmingham West Midlands B33 8RN 0121 783 3444 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) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Miss Tammy Sarah Woollaston Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only Care Home Only (Code PC) To service users of the following gender: Female Whose primary care needs on admission to the home are within the following categories: 2. Learning Disability (LD) 5 The maximum number of service users to be accommodated is 5. Date of last inspection 24th February 2007 Brief Description of the Service: 233 Yardley Fields Road is a five bed roomed bungalow situated in a residential area of Stechford in Birmingham. The premises are owned by Lonsdale (Midland) Limited. The home is situated close to local amenities and shops and public transport. The people who live in the home can also travel by use of the homes own car. The home offers accommodation and care to five adults with learning disabilities, the current client group are all females. All bedrooms are single status and include a wash hand basin. The communal bathing facilities have been adapted to meet the needs of the women living in the home whose ages are progressing towards older persons. There is a lounge, dining room and spacious kitchen. The rear garden is accessed from the kitchen, which is attractive, secluded and well maintained. The home is well appointed, furnished to a high standard and very appealing. The service user guide does not include the fee rate, details of the differing elements of how it is made up or details of services that are not included within it. The home needs to provide these details when a copy of the service user guide is issued to a prospective resident of the home. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out; this is to enable the inspector to obtain an accurate picture of the standards of the services provided. On the day of the visit, there were five people living at the home. Assistance with the inspection process was provided by the manager. At the conclusion feedback was given to the manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside at the home and staff. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A full tour of the premises was carried out. Two of the five care plans reviewed and one was case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people and the standards of care provision. Prior to the visit the home had completed the annual quality assurance assessment and returned it to us. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. A number of people who live at the home were requested by the inspector to complete a questionnaire. These give personal opinions about the services provided and are included in this report. The focus of inspections undertaken by us is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 6 What the service does well: Care plans are very comprehensive. They identify a persons needs, assessments and what measures to be put into place to meet that individuals needs. They describe in detail what staff should do to maintain the persons preferred lifestyle and wellbeing. Staff adopt a proactive approach to peoples healthcare needs. Access to a range of external healthcare professionals is good; this ensures that peoples’ health and wellbeing are being ensured as much as possible. People who live in the home choose how they wish to spend their time and any requests made for an activity is organised by a member of staff. They are also encouraged and supported in developing and maintaining their daily living routines and tasks to assist with the day to day running of the home. The meal menus are decided upon by the people living in the home. Staff encourage and incorporate healthier options as much as possible to promote peoples health. Personal care needs are very well met. Staff provide ample encouragement to assist people in making decisions about how they wish to dress, their hairstyles and purchasing of new clothes. People are regularly asked if there is anything they would like to change. This was evidenced in the minutes of meetings that had been held and from observations during the visit. People are encouraged and supported in participating in a range of activities, educational courses, day centre attendance, outings and holidays. Regular meetings are held and if a request is made staff will make the necessary arrangements. A person said, “I go out shopping, I go to the theatre, I went to a party last Sunday, I went on a cruise in September, I have been to Windermere”. During the visit one person was escorted for her weekly trip to the swimming baths. The inspector was shown photographs of a recent trip to Lapland. Staff encourage people in maintaining their daily living skills. The occupant of each bedroom is responsible for keeping it tidy and clean and people assist with the weekly food shopping. One person said, “I help in the kitchen, I do the washing up”. The premises are furnished to a high standard and are homely with lots of personal items in the communal areas as well as bedrooms. The décor is in good condition and in keeping with the age group of the current occupants. The home has an annual maintenance plan, which identifies areas of improvements. During the visit a maintenance operative arrived at the home to erect blinds, to do grouting of tiles and repair the seal around the shower tray. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 7 The manager has been in post for five years, she has a great deal of knowledge about management of the home, the care that each person requires and is thought highly of by members of staff. She ensures that the home is well organised and treats health and safety as a priority to protect people from risks of injuries. What has improved since the last inspection? The four requirements made at the last inspection had been fully addressed and no requirements have been made from this inspection. This indicates that staff view inspections as a positive experience and where action is needed it is dealt with. The topic of activities has been incorporated into the weekly individual meetings to enable staff to arrange for extra requests to be met. Staff have introduced cooking skills into peoples daily lifestyles to encourage their abilities. Staff have received training in equality and diversity to ensure that equal opportunities are complied with within their associated responsibilities. Staff explore peoples needs regarding spiritual preferences. Due to the ageing of people living in the home staff have undertaken training in care of older persons and physiotherapy to assist in their gradual mobility restrictions. The role of the key worker has been further developed to incorporate more responsibilities, which have resulted in enhancement of peoples’ life experiences. The system is based on a person centred approach to assessing peoples’ needs and preferences. Formal reviews of care plans have been introduced, these are carried out six monthly. This was evidenced during the visit. In the meantime regular reviews of care plans are carried out by staff to ensure that they remain relevant at all times. Peoples identity cards have been improved for when they out in the community in the event that they get lost. The manager has created a sensory room in the area that was originally the garage. This provides a quiet area where people can relax on a one to one basis with a member of staff. The laundry room has been painted. Foot operated bins have been purchased for all communal rooms. One bedroom has been redecorated and furnished; the occupant chose the colour scheme and style of furniture. New easy chairs have been provided for the lounge. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 8 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. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 9 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 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 10 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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home fully demonstrates its ability to meet peoples’ needs by provision of comprehensive written details about the services provided and extensive preadmission arrangements and assessment. EVIDENCE: The statement of purpose is laminated and reflects the recent change of ownership. Both the statement of purpose and service user guide include pictorial explanations of each paragraph and pictures of the fire alarm system and smoke detectors. The service user guide also contains a section about ‘your rights’ and a copy was found in each bedroom. This indicates that people who are considering a placement and those who live in the home have access to information about the services provided. There has not been a new admission since the last inspection; the process for an admission was reviewed. The pre-admission assessment tool is very extensive suggesting that the assessor would obtain detailed information about the persons needs, daily living skills and lifestyle preferences. The manager advised that reports would be obtained from other professionals to contribute to the assessment process. Prospective people are invited to look around the home and a range of other visits would be organised including an overnight stay. Part of the assessment would include integration with the people who 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 11 already live there to ensure that they would get on well with each other. The arrangements suggest that all aspects are explored before a placement is offered. The home does not accept emergency admissions. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. Care plans are effective and meet peoples needs, choices and preferences about how they wish to live. EVIDENCE: Each person has a written care plan. This is an individual plan about what the person is able to do independently and states what assistance is required from staff for the person to maintain their needs and lifestyle. Care plans include risk assessments about the individuals’ activities within the home and the community. These identify the risks and a description of what action is needed to minimise those risks. Care plans should be reviewed regularly to ensure that they are up to date and pertinent to the persons needs. Two care plans were reviewed, one of these was also case tracked and therefore looked at in detail, the full arrangements for the person’ needs were explored. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 13 The care plans had been developed in the presence of the respective person and where possible their representative. The files were found to be extensive and covered all aspects of care and health needs as well as very detailed information about the persons preferred lifestyle. The home is commended for the effort that has gone into preparing excellent details about people. The files contain information about personal needs and a full description of what staff need to do to bridge any identified gaps in the persons ability to meet their own needs. Examples of information were, ‘how I dress, the meals I enjoy, how I access the community, I enjoy the garden and night time routines. Someone said, “I go to bed when I want to, I used to live at another home, I prefer this one”. A comprehensive life history and background information document was found. Part of the files are about communication and activities, these include picture symbols. Photographs were maintained about where people had lived, where they live now and important people such as family members, friends and staff. Pictures of happy and sad faces had been incorporated for particular activities and food like/dislikes. There was detailed information about dietary needs and favourite foods. People had action plans; these identify their aspirations and other leisure pursuits for the coming month and how they were met. Care plans have been written to include clear and concise information about each objective. There were numerous risk assessments in place for each activity carried out both in the home and externally. Where risks were identified a management plan had been developed to minimise the risks. Care plans and risk assessments were being regularly reviewed and since the last inspection the home has introduced six monthly formal (in depth) reviews. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. The home has fully demonstrated that peoples’ lifestyles and personal preferences are a paramount aspect of the service provided. Staff encourage people to eat a healthy diet as far as practically possible. EVIDENCE: From viewing care plans and from observations during the inspection there was good evidence that people are supported in leading an independent and varied lifestyle. Daily living skills such as cooking, maintaining their bedroom, laundry tasks and food shopping are strongly encouraged. Care plans include a wealth of information about leisure pursuits. They include going to the cinema, theatre, pantomimes, shopping, swimming, bath spa and massages, sessions in the sensory room, going to parties, watching films, numerous board games and music. People are supported in going to a holiday 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 15 destination of their choice either in this country or in Europe such as Paris Disney Land. Care plans include details about a persons’ strengths and weaknesses to enable staff to provide the necessary support for them to achieve their aims. Healthcare needs are part of the considerations identified when people decide on their lifestyle and leisure objectives. One person spoken with was knitting, she said, “I’m making a peg bag, I play bingo and games”. Files contained lots of information about peoples’ relatives and friends and how contacts are maintained. Special occasions such as birthdays and Bank Holidays are celebrated with a party. People are invited to parties at other homes within the organisation such as a recent 60th birthday party. People were still talking about it during the inspection. There was evidence in a file that a person had been receiving the support of an advocate who had been acting as her representative to ensure that the person made decisions about how she wishes to live. Weekly one to one meetings are held with the respective key worker to check that the activities programme for the coming week suits the persons’ wishes. Staff also explore any spiritual needs of people. Monthly group meetings are also held; the minutes suggest that a varied range of topics are discussed that affect the way people live. A recent initiative was review of the meal menu by people who live in the home. Having negotiated with people, the menu has been re-written. The evening meal constitutes the main meal of the day. During the visit people were enjoying cheese on toast for lunch. They were joined by staff who sat and socialised with people. Someone said, “We’ve got chicken tonight, I chose it”. There was a relaxed atmosphere and people were noted to have positive relationships with staff, which indicated that there was a sense trust between them. A carer was overheard making suggestions when a person was trying to make a decision about an activity. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 16 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): 18,19,21 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ healthcare needs are well met; this promotes their health and wellbeing. EVIDENCE: Healthcare records were found to be comprehensive. Health action plans were in place detailing the individual health condition and what needs to be done to promote improvements and to monitor the individual. There was evidence of regular input of external professions and people were being supported in attending GP and hospital appointments. Other health checks were being carried out such as dentist and opticians. All input of external professionals had been recorded including the reason, outcome and any treatments and monitoring that staff need to complete to ensure appropriate progress is being made. Some people have lived in the home for a long time and are no longer classed as being younger adults. The care plans covered the necessary aspects such as checking a persons skin integrity and assessments and monitoring of 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 17 individuals mobility. Staff had also attended training in care of elderly people and the type of physiotherapy that may help. Where health conditions had been noted appropriate advise had been sought and care plans further developed. There was comprehensive staff guidance about how to respond to conditions and an effective monitoring system in place for the person who suffers from epilepsy. A member of staff had found an abnormality and it had been promptly reported to a GP. This suggests that staff carry out good observations of the people they are caring for. The management of medications was found to be good; this means that people receive their medications, as prescribed. Staff carry out two audits of the medication every day and record their findings. When medications are administered this is carried out by two staff to ensure that no errors are made. Staff are not permitted to administer medications until they have competed appropriate training. Records of medications returned to the pharmacy are maintained. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. People know how to make a complaint and are confident that it would be dealt with appropriately. The arrangements for adult protection are robust and this protects people from risks of abuse. EVIDENCE: The written complaints procedure gives people sufficient information about how to make a complaints and how it would be dealt with. Since the last inspection the home had received two anonymous complaints and we had also received two anonymous complaints. Senior personnel in the organisation were asked to carry out the investigations. None of the allegations were upheld and it was concluded that the same person may possibly have made the complaints. The written adult protection policy is extensive and gives clear staff guidance on how to respond when abuse is suspected. All staff have received training in this aspect of care. No issues have been raised about adult protection during the previous year. The home has a safekeeping facility for people to deposit small amounts of personal monies. Records of transactions were noted to be satisfactory. 233 Yardley Fields Road DS0000071280.V357271.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): 24,26,27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with safe, comfortable, hygienic and homely accommodation that is furnished and decorated to a high standard. EVIDENCE: The bungalow is spacious and provides appealing accommodation that is age appropriate for the people who live there. A tour of the premises was carried out and without exception all areas were found to be very clean. The lounge faces onto a rear garden, which is attractively laid out and well used by people during the summer time. A large kitchen leads onto a pleasant dining room. The laundry room is supplied with a washing machine that has a sluice cycle and staff are supplied with dissolvable (alginate) bags for soiled items. The soft furnishings were attractive and peoples’ personal items were seen in the communal rooms as well as their own bedroom. There is an ongoing maintenance programme and some work was being carried out on the day of the visit. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 20 There is a large communal toilet to permit staff in providing assistance when needed. The spacious bathroom houses an assisted bath, separate shower, wash hand basin, toilet and grab rails. Work was being carried out to re-seal the shower tray. All bedrooms were noted to be personalised to suit the occupant’s preferences. Each room had a television. The manager advised of the plan to redecorate and refurnish one bedroom. The occupant said, “I’m going to have my bedroom wallpapered, I’ll choose it first”. The bathroom, toilet and all bedrooms have a call system so that people can summon assistance. 233 Yardley Fields Road DS0000071280.V357271.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): 32,34 and 35. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are rostered to meet people’s needs. Staff are adequately trained to provide them with the knowledge and skills to carry out their roles effectively. EVIDENCE: A review of recent staffing rotas indicated that adequate staff are available to provide the care and support for activities for the current client group. Three staff are allocated during daytime hours and two each night. The personnel files of the two latest recruits and another member of staff were checked. These indicated that the home carries out all necessary checks and obtains two written satisfactory references before a position is confirmed. The arrangements serve to protect people living in the home from risks of abuse. Staff training details are maintained on individuals files. They indicated that staff had completed courses in regular manual handling, risk assessments, food hygiene, COSHH (control of substances hazardous to health), equal opportunities, confidentiality, adult protection, fire safety and epilepsy. Newly 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 22 appointed staff complete an induction programme that provides them with the basic skills to carry out their role within the specialty they are employed in. One member of staff had successfully completed training in NVQ level 2. It is recommended that more staff undertake this training. 233 Yardley Fields Road DS0000071280.V357271.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 excellent. This judgement has been made using available evidence including a visit to this service. The manager is supported by an effective staff team in the day to day running of the home. The quality assurance programme demonstrates that the home is constantly striving to make improvements for the benefit of the people who live in the home. Health and safety arrangements are robust and protect people from risks of accidents. EVIDENCE: The registered manager has been on post for five years and during this time has made sustained improvements to the running of the home to the degree that no requirements have been made as a result of this inspection. The deputy manager had recently left having achieved promotion. The manager was actively recruiting to employ two team leaders to replace the deputy managers’ post. 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 24 Both people living in the home and staff provided positive comments about the manager and the level of support she provides. The home receives monthly, unannounced visits from a senior person within the organisation and a written report is supplied to the manager. The home is currently adapting to the new owners system for quality assurance. This involves the manager carrying out an audit of the services, premises and standards of care and recording the findings. The document used includes a section for recording shortfalls and what act will be taken to address them. Upon completion a survey of they audit is carried out by a visit from a person within upper management to verify the managers’ findings. Following this a report is written and supplied to the manager to share with people living in the home and staff with an action plan for rectifying any agreed shortfalls. Regular staff meetings are held to discuss and minute the running of the home; peoples care needs and where changes or improvements could be made. Maintenance records of servicing and checks carried out on equipment and the premises are good. Regular checks of the fire alarm system are being carried out and recorded. A fire safety risk assessment is in place as well as numerous risk assessments on the premises. The health and safety arrangements serve to protect those people living and working in the home form risks of injuries. 233 Yardley Fields Road DS0000071280.V357271.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 CHOICE OF HOME Standard No Score 1 3 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 X 3 X X 3 x 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 26 No 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA1 Good Practice Recommendations It is recommended that written details of the fee rate, how the various elements are calculated and details of services that are not included are developed for distribution with the service user guide. It is recommended that at least 50 of care staff should complete the NVQ level 2 training. It is recommended that the quality assurance report be produced in an understandable format for people living in the home. 2. 3. YA32 YA39 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 27 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 233 Yardley Fields Road DS0000071280.V357271.R01.S.doc Version 5.2 Page 28 - 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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