Care Home: 8 Trescott Road

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Aston Court Nursing Home
• Polesworth Group 70 Long Street
• Breme
• Ravenhurst
• Polesworth Group 64 Long Street

What the care home does well Staff have good knowledge of peoples needs and how they should be provided. This ensures that people receive personal care to promote their well being. People have choices about what they want to eat and drink and whether they want a full meal or a snack. Staff support people in making choices about places they would like to go to enhance the quality of their lifestyles. The arrangements for administration of medications are good. This ensures that people receive their prescribed medications appropriately to promote good health. Systems have been developed to enable staff to communicate well with individuals. This assists in people`s ability to hold conversations, participate in recreations and to make a complaint if they are unhappy about something. Staff ensure that a homely atmosphere is maintained so that people are made to feel that they belong to the home. A positive and happy atmosphere was noted in the home during the fieldwork visit. Senior staff consider health and safety to be an important aspect of the services. This protects people from risks of injuries. The home has a core of staff who have been employed for a long period of time. This indicates their enjoyment of their roles and provides continuity for people who live there. People are actively encouraged and supported in making decisions and taking appropriate action about their health. What has improved since the last inspection? The service user guide is now available in audiocassette format to assist people in understanding the services the can expect to receive if they are considering living in the home. Learning logs have been introduced for recordings to be made about the activities that people have participated in and if they enjoyed them. This enables staff to monitor peoples` preferences and to make changes when necessary. Following feedback received form people who live in the home the activities have been reviewed and changes made. This suggests that people are actively involved in making decisions about their lifestyles. The home is moving towards person centred care planning. Staff are currently receiving training in this before the home commences implementation. This will evidence that people who live in the home are at the heart of the services provided.Some individuals have made pictures and these are on display on the lounge wall. This indicates that peoples` abilities and skills are recognised and appreciated. From feedback given by people living in the home about the garden, there are plans to remove the raised flowerbed to improve their access. People who live at the home have received training in the interview process and now take an active role when people apply to work at the home. This confirms that they influence the way the home operates and who works there. CARE HOME ADULTS 18-65 Trescott Road (8) Northfield Birmingham West Midlands B31 5QA Lead Inspector Kath Strong Key Unannounced Inspection 26th November 2007 11:30 Trescott Road (8) DS0000016936.V353715.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 Trescott Road (8) DS0000016936.V353715.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. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trescott Road (8) Address Northfield Birmingham West Midlands B31 5QA 0121 475 9585 F/P 0121 475 9585 debbiep@trident_ha.org.uk www.trident-ha.org.uk Trident Housing Association 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) vacant post Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years, with a learning disability which may also include associated physical disabilities. 8th November 2006 Date of last inspection Brief Description of the Service: 8 Trescott Road is registered for seven people who have a learning disability who may also have physical disabilities. It is a purpose built residential home. The layout and design offers an accessible and spacious facility. The home is equipped with en suite facilities for all seven bedrooms. A stair lift provides access to two bedrooms, office and staff sleep-in facilities are located on the first floor. It is unfortunate that a purpose built home for people who have physical disabilities cannot be accessed by people who are wheelchair users. Five of the service users cannot access the first floor. Ground floor accommodation includes five en suite bedrooms, a large open plan dining room/lounge and a conservatory. The kitchen is accessed off the dining area. To the rear of the home there is an enclosed garden, there are plans to develop the garden so that it could be utilised more by the people living in the home. To the front of the home there is off street parking for a number of cars. Details of the current fee rate is available upon discussion with the manager by people who are interested in moving into the home. The latest CSCI inspection report is available in the reception area of the home for visitors if they wish to read it. Trescott Road (8) DS0000016936.V353715.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 seven people living at the home. The manage provided assistance with the inspection process. At the conclusion verbal 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. An independent service user of learning disability services (expert by experience) assisted with the inspection process. He explored the means of communications with people who live in the home, their activities and night time communications. A copy of his report is included in the body of this report. Health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Two care plans were reviewed and 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. 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. What the service does well: Staff have good knowledge of peoples needs and how they should be provided. This ensures that people receive personal care to promote their well being. People have choices about what they want to eat and drink and whether they want a full meal or a snack. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 6 Staff support people in making choices about places they would like to go to enhance the quality of their lifestyles. The arrangements for administration of medications are good. This ensures that people receive their prescribed medications appropriately to promote good health. Systems have been developed to enable staff to communicate well with individuals. This assists in people’s ability to hold conversations, participate in recreations and to make a complaint if they are unhappy about something. Staff ensure that a homely atmosphere is maintained so that people are made to feel that they belong to the home. A positive and happy atmosphere was noted in the home during the fieldwork visit. Senior staff consider health and safety to be an important aspect of the services. This protects people from risks of injuries. The home has a core of staff who have been employed for a long period of time. This indicates their enjoyment of their roles and provides continuity for people who live there. People are actively encouraged and supported in making decisions and taking appropriate action about their health. What has improved since the last inspection? The service user guide is now available in audiocassette format to assist people in understanding the services the can expect to receive if they are considering living in the home. Learning logs have been introduced for recordings to be made about the activities that people have participated in and if they enjoyed them. This enables staff to monitor peoples’ preferences and to make changes when necessary. Following feedback received form people who live in the home the activities have been reviewed and changes made. This suggests that people are actively involved in making decisions about their lifestyles. The home is moving towards person centred care planning. Staff are currently receiving training in this before the home commences implementation. This will evidence that people who live in the home are at the heart of the services provided. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 7 Some individuals have made pictures and these are on display on the lounge wall. This indicates that peoples’ abilities and skills are recognised and appreciated. From feedback given by people living in the home about the garden, there are plans to remove the raised flowerbed to improve their access. People who live at the home have received training in the interview process and now take an active role when people apply to work at the home. This confirms that they influence the way the home operates and who works there. 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. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 8 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 Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 9 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, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are given good written/audio details about the services for them to make an informed decision about moving in to the home. Information is gathered from various sources and a comprehensive pre-admission assessment is carried out by the manager to ensure that the home that it is able to meet individuals’ needs at the time of admission. People are supplied with written terms and conditions so that they are made aware of the services they can expect to receive. EVIDENCE: The statement of purpose was reviewed and found to contain sufficient information about the home. The service user guide is available in written, pictorial and audiocassette format to assist people in their understanding of it. The current fee rate is supplied separately and people are able to discuss this with the manager. Senior staff gather information, reports and social worker assessments as part of the pre-admission assessment process. The manager also carries out an assessment to determine that the facilities are adequate to meet the persons’ needs. Also that works such as bathroom refurbishments are completed prior to the date of admission. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 10 Each person is issued with a contract of terms and conditions of residency. This gives people guidance about their rights whilst living in the home. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are provided with ample information to enable then to provide the necessary care needs and support for people to lead an independent lifestyle. People make decisions about the way in which they wish to live and staff provide encouragement and support for them to achieve this. People are able to take informed risks about their daily activities. EVIDENCE: The files of two people were reviewed to ascertain the levels of care needed and how these are being provided. The files included how staff need to communicate with them because of restricted verbal communication skills. They detailed how staff are to support them to meet their individual needs regarding personal care, heath needs, eating mobility, finances, behaviour, medications, emotional, relationships, psychological, religion, culture and leisure activities. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 12 Reviews are carried out with the input, where possible of the individual, relatives, advocates, healthcare professionals and the home manager. Files seen indicated that much emphasis is placed upon development of a working communications system that ensures that the individual has his/her say about how their health and personal care needs are provided and what activities they wish to be involved with. Observations indicated that staff had developed a good understanding of peoples’ means of communicating and they were able to respond appropriately. The relationships between people living in the home and staff appeared to be relaxed and friendly. Regular meetings are held, these are chaired by a senior person within the organisation. The written minutes are also produced in audiocassette to enable people who are not able to read, to remind themselves of what was said and agreed during the meetings. There was ample evidence that recreations such as outings and holidays are discussed and arrangements formalised for these to happen. On the day of the fieldwork visit one person living in the home requested that the Christmas decorations be put up. By the end of the visit staff were seen sorting out items and putting them up. Files contain detailed information about the respective persons background, life history, likes and dislikes. These provide staff with good details about the person and their personal preferences to enable them to build up a comprehensive programme that meets the respective persons aspirations. Files included up to date risk assessments. These stated what the activity involved, the risks and what action is needed to minimise the risks as far as possible. They included such things as mobilising, moving and handling, financial issues, fire, eating and drinking, various outings and use of wheelchairs. This suggests that where possible staff take good precautions to protect people from risks of accidents and injuries. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 13 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, 14, 15 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to enable people to have a meaningful lifestyle and to make decisions about how they wish to live. People are encouraged to choose what they wish to eat and staff support people in healthy eating to promote their health and wellbeing. EVIDENCE: Five people go to day centres for some or the whole of the weekdays and some attend college courses. Funding arrangements were in place for the people who choose to remain in the home to enable staff availability to care for them and to support them in going out if they wish to do so. Files indicated that people go out to restaurants, pubs, concerts, various clubs and to celebrations such as bonfire parties. There was evidence that people make decisions and that staff accommodate changes at short notice when people change their minds. Monthly meetings are held with each person in the Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 14 home and the activities programme for the coming month is agreed and staff make any necessary arrangements towards ensuring that the programme is fulfilled. One person sometimes attends church for religious celebrations. Regular outings are arranged and people are supported in going on holiday to a destination of their choosing. Risk assessments are carried out for these occasions. The processes for the safe storage and transactions of personal monies held on behalf of people were found to be robust. This ensures that people are protected from risks of financial abuse. Two of the three areas looked at by the expert by experience are as follows: We spoke to 3 out of the 7 residents. This was due to the other residents having no verbal communication. I did sit and observe how staff and residents interacted with each other. 1: Communication Staff seem friendly and get on with the residents really well. Staff seem to know what the residents needs are. The staff told me some of the things that the residents like. For example ….. likes to have his head stroked, I saw the staff do this and ….. started smiling and making noises. As soon as the staff member stopped this, he reached out for the staff members hand. I observed the staff asking each resident what drink they would like. I thought that it was good that the staff asked ….. and …. even though they cannot verbally communicate. ….. seemed to understand what the staff member asked him. Again he smiled and made noises. Staff came and sat with the residents and talked to them. There was a change over of staff while I was there and the staff that went off duty said goodbye to the residents and the staff that started their shift said hello to the residents. I think that this is important. Staff involved some of the residents in making drinks and doing the laundry. 2: Activities I feel that the residents should do more activities out in the community on a weekly basis. Some of the residents go to daycentre during the day. One resident said that they go shopping for some the week. One staff member told us that the other Trident homes invite each other over when it’s someone’s birthday, this is nice, but it shouldn’t just be birthdays or special occasions when people get together. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 15 The residents were going to make Christmas cards this evening but I didn’t see any evidence that in house activities take place on a regular basis. Overall view of the home Trescott Road seems a nice home. The staff made an effort to talk to me and offer me lots of drinks, which I thought was nice. I felt as ease in the home. The residents seem to get on with each other, they seemed in a good mood and a couple of the residents were talking to each other. ….. had a sensory hammer which he seemed content with. There was a fire procedure on the wall in easy words and pictures, I thought this was good. I liked the layout of the lounge and the dining room being open planned as it was easy to move the residents around who were in wheelchairs. The menus indicate that a varied, balanced and nutritious diet is provided. The main meal of the day is prepared in the evening and always offers two choices. Peoples likes and dislikes are accommodated and alternatives are offered. Staff sit with people during the meal to provide assistance and to chat with people. Where possible people were encouraged to eat and drink independently. Equipment such as plate guards and non-slip mats were in use to further promote independence. Staff also follow any advice provided by speech and language regarding specific intakes and how this is successfully achieved. Trescott Road (8) DS0000016936.V353715.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Monitoring of healthcare needs requires some improvements but in practice people’s personal and healthcare needs are being well met. The management of medications are good thus, peoples health is being promoted. EVIDENCE: The care plans include good information about healthcare needs and how they will be met. There was good information about illnesses that may result in complications such as seizures or difficulties in swallowing. Files were being regularly reviewed and relevant others were invited to attend formal reviews. Each person has a Health Action Plan. This is a personal plan that describes what is needed for the person to remain healthy and what other services are needed. Some information is in pictorial format to assist the owner of the care plan in understanding it. People are weighed regularly to monitor their weight so that staff can take action if weight loss is identified. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 17 The records sampled included details about pressure area assessments that had been carried out for those who are prone to development of pressure ulcers. One file indicated that the Waterlow assessment had not been reviewed since March 2006. The home needs to carry out regular assessments in order to monitor peoples’ needs effectively. This was raised during the previous inspection but had not been addressed and should be treated as a matter of priority. There was comprehensive information about the input of healthcare professionals and where advice had been provided how staff would implement it. The files indicated that there was input from a wide range of people in order to meet individuals’ physical and mental health needs. Details in respect of personal care included what people can do for themselves and occasions when they need encouragement to do the task themselves to promote their independent living skills. The third area looked at the expert by experience is as follows: Night time support One resident said “I tell staff when I need them, they help me day or night and I feel safe here”. Another resident told me “I go to bed about 9oclock but I could go later if I wanted to” I was unable to get any more information about what happens on an evening or night time support, the residents I spoke to didn’t answer any more of my questions. My only concern is that people stay in their wheelchairs all the time, maybe wherever possible they could go into adapted more comfortable chairs. Medication is stored in a locked cabinet in the kitchen. Medications were stored in a tidy and hygienic fashion. Staff who have received training are permitted to administer medications. Auditing was carried out of the two people whose care plans were seen, they were found to be correct. Controlled drugs were stored safely and regular checks are carried out to check accuracy. Recordings were seen to be good. The arrangements appeared to be good in ensuring that people receive their prescribed medications appropriately. Trescott Road (8) DS0000016936.V353715.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 excellent. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to ensure that peoples’ opinions are listened to and that they are able to make a complaint. The process for management of adult protection is such that it adequately protects people from risks of harm. EVIDENCE: The complaints procedure is in written, pictorial and audiocassette formats to assist people in making complaints. CSCI had not received a complaint since the last inspection. One complaint had recently been made and a member of staff had acted as the person’s advocate. This is viewed as being very good practice. The complaint had been made very recently prior to the fieldwork visit therefore the outcome was not available. The complaint concerned the organisations failure to undertake some repair works and to redecorate a bedroom. Trident had confirmed that this work would be carried out after the arrival of the occupant but had failed to do so. A visit to the room confirmed that work was needed; the room gave a slightly shabby appearance and was not acceptable for the occupant. The person had not been able to personalise the room to his liking. The written policy concerning adult protection was found to be comprehensive. The document makes references to Birmingham multi-agency guidelines and peoples right to advocacy services. Staff have received training in this aspect of care. No issues have been raised by the home or CSCI. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 19 The home also has a good missing person policy for staff to follow if necessary. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 20 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, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole people are offered warm, comfortable and a safe environment to live in. EVIDENCE: Communal areas are spacious and furnished in such a style as to promote a homely feel. There were soft furnishings and ornaments to enhance the appearance of the home. The furnishings were noted to be age appropriate. There was ample access for specialist wheelchairs to manoeuvre and to park where others were seated on domestic furniture to enable a group setting where conversation s could easily be held. The kitchen provides adequate space for someone to join staff each evening to assist ion preparation of the evening meal. Cupboards had pictures on the doors to help people in identifying the contents of them. The home was found to be tidy and very hygienic throughout. There was no evidence of offensive odours. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 21 There was specialist equipment for people and each bedroom has adapted ensuite bathing equipment to suit the needs of the occupant. As discussed previously, one bedroom, which was occupied earlier in the year was noted to be in need of some repairs and redecoration. This requires attention to enable the occupant to personalise it and to ensure a pleasing personal space is provided. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 22 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. The arrangements for staffing the home is variable, it requires review to ensure that people are supported in leading a fulfilling lifestyle. Lack of staff induction and training is not ensuring that they possess the knowledge and skills to provide for peoples specialist needs. EVIDENCE: The annual quality assurance assessment that had been completed by the home indicated that 73 of carers had successfully completed NVQ level 2 in care and another carer was currently undertaking the course. This exceeds the requirement of a minimum of 50 . The home enjoys a core of staff who have been employed for a significant period of time. This suggests that staff are happy with their roles and motivated towards caring for people. These carers also ensure that people who live in the home have continuity of care. People who live in the home are supported by three carers during daytime hours and one at night with an additional carer sleeping in. The manager Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 23 advised that there were some extra flexible daytime hours available for an extra staff to assist with activities. In view of the findings of the expert by experience regarding inadequate outings these hours should be reviewed. Regular staff meetings are held, these were evidenced from the minutes that are produced and circulated. Checking of staff files indicated that some sections about recruitment were not available for inspection. The manager advised that she was aware of the problem and was working on resolving it. There was no evidence in the home that newly appointed care staff undertake an induction programme that reflects the contents of a recognised accredited programme such a Skills for Care or LDAF. A further concern was found regarding the in-house moving and handling trainer who had continued to carry out refresher training although her certificate had lapsed in 2005. All moving and handling training must be accredited and provided by an accredited trainer. It was noted that some staff had not received formal refresher training since 200/04 and one instance of 2001. The home is failing to provide regular refresher training. Other mandatory courses had been completed and further training had been arranged in respect of food hygiene and health and safety. Staff have also had training in care of people who suffer from epilepsy. Other courses had been arranged for the mental capacity act, fire awareness, safer people handling and first aid. This indicates that with the exception of moving and handling staff are provided with the knowledge and skills to carry out their roles effectively and safely. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. The manager is experienced ands possesses the skills to oversee the day to day management of the home. The quality assurance programme needs to be further developed to evidence that sustained improvements are made for the benefit of the people who live in the home. Arrangements in respect of health and safety are robust and prevents the risk of avoidable injuries from occurring. EVIDENCE: Since the last inspection the organisation has recruited a new manager who had been in post almost three months. She has wealth of experience in the care sector including management. She has a certificate in mental health and has completed NVQ level 4 in management. An application has been submitted to us for her registration. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 25 A deputy manager post has recently been created and the home is actively recruiting to fill the vacancy. A further 2.5 whole time equivalent carer vacancies were also being worked on and interviews had been arranged for these. The organisation has an on call system whereby a manager is available to deal with any support that staff may need during out of office hours. The system is backed up by a senior manager who is also on call and is able to deal with any serious incidents that may occur. Unannounced monthly visits are being carried out by a senior manager and a report developed and supplied to the manager. This indicates some degree of ongoing monitoring of the home and the standards of the services provided is being carried out. The manager advised that she was not aware of a formal quality assurance programme. The organisation needs to demonstrate that a process is in place that results in an annual report that can be shared with us and other professionals upon request. The accident records are good and there was evidence of further actions having been taken resulting in a reduction of injuries. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting systems and the results recorded to protect people from injuries in the event of an emergency situation. Hot water temperatures are tested and the findings recorded to prevent people from the risk of scalds. Regular fire drills are carried out and the names of those staff who have participated are recorded to ensure that all staff are captured during each twelve month period. The health and safety arrangements appear to protect people fro risks of injuries. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 26 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 3 29 3 30 X STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x Trescott Road (8) DS0000016936.V353715.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 YA19 Regulation 12 (1)(a) Requirement Pressure area assessments must be regularly reviewed and recorded to demonstrate that effective monitoring is being carried out for people who have restricted mobility. Timescale of 30/11/06 has not been met therefore immediate action is required to prevent enforcement. 2. YA26 23(2)(b)(d) The bedroom of the latest 31/01/08 admission must be repaired and redecorated to ensure that it is fit for purpose and to enable the occupant to personalise it. 7919, Sch 2 Recruitment records must be available in the home for all staff employed there. Timescale of 31/12/06 has not been met therefore immediate action is required to prevent enforcement. 4. YA35 18 (1)(a, c) All staff must have accredited updated training in moving and handling provided by an DS0000016936.V353715.R01.S.doc Timescale for action 31/12/07 3. YA34 29/02/08 31/01/08 Trescott Road (8) Version 5.2 Page 28 accredited trainer. This is required to provide staff with the up to date knowledge and skills to carry out their roles effectively and safely. Timescale of 31/01/07 has not been met therefore immediate action is required to prevent enforcement. The home must demonstrate that newly recruited staff are expected to undertake a formal accredited induction programme to provide them with the basic knowledge and skills to provide appropriate care foe people living in the home. 5. YA39 24(2) A formal quality assurance programme must be developed that takes into account stakeholders opinions. An annual report must be collated that includes good practices and shortfalls and how and when they will be addressed. This is required for the home to demonstrate that it is making continual improvements for the benefit of the people who live there. 31/03/08 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 YA13 Good Practice Recommendations A review of available staff should be carried out to ensure that people living in the home are having sufficient access DS0000016936.V353715.R01.S.doc Version 5.2 Page 29 Trescott Road (8) to the community and other activities. Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stepehenson 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 Trescott Road (8) DS0000016936.V353715.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!