Latest Inspection
This is the latest available inspection report for this service, carried out on 9th October 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for 29 Greenhill Road (westholme).
Annual service review
Name of Service: 29 Greenhill Road (westholme) The quality rating for this care home is: The rating was made on: two star good service 2 8 1 0 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Kerry Coulter Date of this annual service review: 1 2 1 0 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Greenhill Road, 29, (westholme) Moseley Birmingham West Midlands B13 9SS 01214496383 01214496573 Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : learning disability physical disability Conditions of registration: TRACS Limited Number of places (if applicable): Under 65 Over 65 14 14 0 0 The maximum number of service users who can be accommodated is: 14 The registered person may provide the following category of service only: Care Home Only (Code PC); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Learning disability (LD) 14, Physical disability (PD) 14 Within the physical disability category 14 service users may be accommodated with an acquired brain injury. Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Conditions of registration have been reviewed. 2 8 1 0 2 0 0 8 Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service 29 Greenhill Road comprises of two units, TRACS Westholme, and TRACS Hilltop. The home is registered to accommodate up to fourteen people who have a Learning
Annual Service Review Page 2 of 6 Disability or Acquired Brain injury. Three of the rooms within the accommodation on the ground floor have been adapted to support people with impaired mobility. The remaining bedrooms are on the first floor and second floors. Westholme has a communal lounge, dining room, smoke room, kitchen, bathrooms and toilets on both floors. Hilltop occupies the second floor of the home. Hilltop provides care and support for up to four people working towards more independent living. It offers people the opportunity to develop skills such as budgeting, cooking, home making and taking greater responsibility for planning their lifestyle. This area of the home has its own facilities such as a lounge, kitchen, laundry and bathroom. The home has a large, mature garden at the rear. The home has its own transport, and is located close to local bus routes. Copies of previous reports are available in the home, on request. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was completed and sent to us by the service. Completion of the AQAA is a legal requirement and it enables the service to undertake a self-assessment, which focuses on how well outcomes are being met for people using the service. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Information about any complaints or safeguarding incidents we received. The previous key inspection findings. We also sent surveys to the home to distribute to eleven people who live there and their relatives, eight staff and four care professionals. At the time of completing this annual service review seven surveys had been received from people at the home, three from relatives, and from three members of staff. What has this told us about the service? People who live at the home told us that they make decisions about what they do each day, that they know who to speak to if they are unhappy, staff treat them well and the home is always fresh and clean. Their comments included: They look after us well. Get on well with staff. Take good care of us. I love living here. Staff listen to concerns I may have. Happy at the moment. Staff help me and assist me to do things for myself. Surveys from staff indicate they get the training and support they need. Staff told us there are usually enough staff on duty to meet peoples needs. Staff comments include: All staff work really well as a team supporting each other. Need to employ a domestic so staff can spend more time with people. Is a fantastic place to work. The survey returned from relatives generally indicated that they thought the service meets the persons needs and supports them to meet the life they choose. Comments included: Professional, reliable and an excellent manager. They are very caring. Ativities are planned and co ordinated to specific needs. The registered manager of the home is currently on maternity leave and the home is being managed by the deputy manager. The deputy manager completed and returned the AQAA to us within the required timescale and it provided us with information about the outcomes for people using the service. They told us that improvements they had made in the last twelve months included: Statement of Purpose and Service User Guides have been updated. We have provided Annual Service Review Page 4 of 6 more care plan training for staff. We have developed care plans to include additional information and allow for more efficient recording. An anti-institutionalisation project was launched and many changes took place following individual audits in the home. Two people now have been involved in compiling their own menu. Auditors are now completing medication audits more frequently and we have implemented more observations of staff practice. After negotiation the local GP now does annual health checks to monitor weight and blood pressure. Several areas of the home have been redecorated. The AQAA tells us that improvements planned for the next twelve months include: More detailed auditing of care plans and related documentation. We are about to implement improved ways of monitoring weight gain and loss. An assessment tool is being implemented to identify people at risk. A new kitchen is planned. An action plan is in place to improve the appearance of the home. This incorporates new lighting, furniture, flooring and redecoration. Demonstrate more focus on spiritual needs by auditing this particular area in care plans and talking with people. We have not received any complaints about the home in the last twelve months. The homes AQAA told us that they had received five complaints directly, one of which they upheld. All complaints were resolved within a twenty-eight day timescale. The AQAA tells us equality and diversity is promoted at the service with all people using the service. They told us: We have a section in our assessment forms and care plan which asks for details of cultural needs and how to meet these needs. We have a religious needs booklet which enables staff to gain understanding of different needs and how to respond to these needs appropriately. We have sexuality training annually for all staff members and we have a policy on sexuality which sets out guidelines for staff on legal aspects and non-discriminatory practice. We provide anti-discriminatory training within our induction period and then more detailed training annually. The home told us they listen to peoples views by: Questionnaires are sent annually to people at the home, these are collated by the quality director.In addition to this we facilitate a client focus day in order to gather additional feedback. In -house meetings are held with people on a monthly basis. A notice is put up in advance to notify people of the next meeting. They are invited to add items to the agenda for discussion. This meeting also enables us to notify clients of any imminent changes to the home or the service. People are given the opportunity to make a complaint at any time. Complaints leaflets are available in the home and a complaints poster is displayed on the wall informing people of how they can complain. The complaints procedure is also explained to people upon admission. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 28/10/2011. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 5 of 6 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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