Care Home: Mercian House

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What the care home does well Service users said they were well looked after and live comfortable. One service user said this is my home I have lived here for a long time and enjoy the company. Records pertaining to health and safety are well maintained and regular checks are completed. Care plan are detailed and show the service users health needs are met. What has improved since the last inspection? Further developments with care plans have given specific information about the service users. Details of history and medical needs are identified. Records in general have improved. What the care home could do better: Financial records need to be more robust and demonstrate adequate audits are completed. Where there are discrepancies this must be explained. Records pertaining to service users finances in some place were inaccurate resulting in the reconciliation being incorrect. Risk assessments must be reviewed and show how the risk is monitored and managed. A quality audit must be completed and show how service user views have been incorporated to ensure the service progression. Recruitment more remains robust and all staff must have the same checks completed when employment has been interrupted for any length of time. Supervision must be completed at least six times per year and incorporated a personal development plan. CARE HOME ADULTS 18-65 Bamville Road (1) Ward End Birmingham West Midlands B8 2TJ Lead Inspector Susan Scully Key Unannounced Inspection 19th February 2007 09:30 Bamville Road (1) DS0000017076.V331027.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 Bamville Road (1) DS0000017076.V331027.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. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bamville Road (1) Address Ward End Birmingham West Midlands B8 2TJ 326 0491 & 688 5797 F/P 0121 688 5797 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) Mrs Janice Hutton Mr Festus Hutton Mrs Janice Hutton Care Home 3 Category(ies) of Learning disability over 65 years of age (3) registration, with number of places Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Bamville Road is a 100 year old, domestic style end of terrace property situated in a residential area and in close proximity to a school within the Ward End vicinity of Birmingham. The home offers accommodation to three people with learning difficulties who have lived at the home for a significant number of years. The facilities include lounge, dining room, kitchen, laundry, rear garden, one ground floor and two first floor bedrooms and a small office. The bedrooms vary in size and one was noted to be quite small. The registered manager has arranged a sheltered area with seating within the rear garden for the service user who smokes; the facility permits staff observation from the kitchen window. The parking facilities for the home are some distance away form the home. The first floor of the home was extended approximately 5 years ago with a view to increasing the accommodation to six service users; to date this has not been progressed although an application was submitted two years ago as it does not meet the existing standard and the application is unresolved. The home is well situated for local amenities, being close to bus and train routes and Ward End shopping facilities. Care is offered with normal lifestyle principals and service users are allowed to go out unaccompanied. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place over a one-day period by two inspectors. Records pertaining to service users were sampled and included: care plans, risk assessments, daily notes, fire Safety records, accident records, complaints, compliments, and staff rotas. Records pertaining to Health and Safety were also sampled, these include Gas Safety checks, electrical appliances testing, water temperatures, infection control, safe storage of Hazardous Substances, food hygiene, manual handling assessments and medication. What the service does well: What has improved since the last inspection? What they could do better: Financial records need to be more robust and demonstrate adequate audits are completed. Where there are discrepancies this must be explained. Records pertaining to service users finances in some place were inaccurate resulting in the reconciliation being incorrect. Risk assessments must be reviewed and show how the risk is monitored and managed. A quality audit must be completed and show how service user views have been incorporated to ensure the service progression. Recruitment more remains robust and all staff must have the same checks completed when employment has been interrupted for any length of time. Supervision must be completed at least six times per year and incorporated a personal development plan. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 6 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. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service user has a contract of terms and condition of residency that includes the amount of fees payable. EVIDENCE: Service users have lived in the same accommodation for the past 10 years. Each service user has a contract of terms and condition that includes the amount of fees payable. The home has a policy that covers new admission giving details of pre assessment, however this was not audited during the visit, as there have been no new admission. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are identified in their individual care plans. Information pertaining to choice and how service users make decisions on a daily basis must be available for inspection. Risk assessments do not fully protect service users. EVIDENCE: The manager has introduced a new care plan format as part of reviewing the care records. Care plan being developed was very detailed and specific with the aims and objectives and how these should be addressed. The care plan included information as to the kind of activities the service user would like to do such as going to the pub or visiting a partner. The care plans also had pen pictures, which contained information about their daily routines including the individual’s preferred time of getting up and going to bed. Two service users were asked if they knew if they had a care plan and both said they didn’t know. The manager must ensure the revised care plans Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 10 provide evidence of the service users’ involvement. The current care plans had been reviewed and evaluated since the last inspection. Although the care plans contained some good information the daily records to audit if the assessed needs where being incorporated on a daily basis was not available for inspection. The manager said she had taken the daily records home as she was completing some information in each dairy. At the previous inspection records were available to show how the service user made decisions on a daily basis. As the records were not available for this inspection it could not be evidence this has continued. When speaking with one service user he said “I do what I want and let the manager know where I am, and where I am going’’. Records pertaining to service users must be available for inspection and remain secure to ensure compliance with Data Protection. An audit trail of the care needs and daily activities of service user could not be completed. Risk assessments are incorporated into care plans. However a risk assessment completed indicated that a service user failed to get of a bus at the right stop. This had been identified in the risk assessment with guidance to staff to show the service user the right bus stop. It was not possible to determining if this was still a risk or whether it had been resolved in the documentation presented. The manager said this had been resolved. Another risk assessment identified a service user was at risk of self-harm this had been completed on 4 October 2005 and had not been reviewed. Another risk assessment identified a service user shouts for no reason but did not identify why this was a risk. There was no information for staff in what action to take if this occurred or how this is monitored. For service users to be fully protected further development is required with risk assessments. Risk assessments must show how each identified risk is managed, monitored and reviewed. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience a lifestyle that suits their needs and preferences. EVIDENCE: Daily records of what activities the service user had participated in was not available for inspection. However one service user said he went out every day, either to a day centre or to visit is partner. The service user said that the manager always took them out either shopping or to lunch, they went on holiday to Jamaica, and they were going again this year. There is always something to do even if it’s watching the football match on TV. The home have assessed the lifestyle needs of the resident and considered through the risk assessment process many health and safety issues. The resident is supported to develop domestic skills with laundry and kitchen through a process of learning. Menus are based on healthy eating plans. Service users were involved in the design and choice of their meals and it was noted individual menus were in place. The manager has developed a four-week menu plan, however if service users chose not to have what is on the menu for that day an alternative is Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 12 offered. Service users are involved in the preparation and cooking of food and are supervised. This enables the service user to develop every day living skills. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported or encouraged to undertake personal care in a way and time suited to them. Staff supports the Service users health needs. The management of medicine practices relating to medication are robust. EVIDENCE: Each care plan details how staff supports service users with their individual needs around personal care There was documented evidence where people had contact with healthcare professionals including a GP, Optician, Dentist and Chiropodist. Medication is stored in locked cabinets in the office. The local pharmacist supplies medication and has done for a number of years this enable the home to ensure continuity and have professional advice if required. Medication Administration Records (MAR) had all been signed appropriately. The MAR cross-referenced with the tablets supplied by the pharmacist. Records indicated that all medication was checked in when it was received from the pharmacy and records clearly demonstrated when medication had been Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 14 returned. Staff complete daily medication audits to ensure all service users medication has been given correctly. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 15 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): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The complaints procedure ensures that service uses views are listened to. Arrangements are not fully adequate to ensure service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is included in the Statement of Purpose and the Service Users Guide and each service user and/or their representative has a copy of this. It would be beneficial to service users who live at the home if this document was available in an accessible format. There had been no complaint recorded since the last inspection. Staff records demonstrated they had received training in adult protection and the home uses the Birmingham Mulity Agency Guideline in line with the Department of Health no secrets. Service users audits pertaining to finances that had been completed require further improvement. Records sampled showed debits and credits to individual accounts inaccurate. The manager must ensure that all credits and debits are recorded and reconciliation before transferring the balance on to a new sheet. Two service user financial records showed they are always in debit. The manager must identify why this is on the recording sheets, and action taken to ensure and establish if there is a more appropriate way in managing their finances. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 16 Risk assessments do not fully protect service users and may potential place them at further risk if reviews are not completed regularly. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 17 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): 24,30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users are happy and comfortable and feel safe in the environment they live in. EVIDENCE: The building was clean and tidy at the time of this inspection. Service users said they were happy with their bedrooms. The bedrooms were personal to the individual with personal belongings. The home was clean and tidy and free from offensive odours throughout. Service users are supported to do their own cleaning and keep their bedroom clean and tidy. Service users appeared comfortable. One service users said “This is my home and I like living here, I am ok and I like my room, and I like my friends who live here’’. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 18 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): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Service users may be placed at risk if recruitment practices are not robust and lack of supervision may have an impact on staff personal development. EVIDENCE: Since the last inspection a member of staff has returned to work at the home. The manager had not completed a return to work interview or a POVA first check (Protection Of Vulnerable Adults). A CRB (Criminal Record Bureau) had not been completed. The manger said she was in the process of completing a CRB, and said the staff member had been working in the home as required for some time in between completing nurse training. The manager must ensure if a member of staff leaves their employment for any length of time robust recruitment procedures must be implemented on their return and include the relevant check. Supervision records had not been completed, for example one staff member received supervision on 16/1/06 10/5/05 and 10/2/05. The member of staff who had returned to work had no supervision records on file. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 19 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): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records demonstrated in general the home was effectively managed. There are gaps in risk assessments, recruitment and the auditing of service users finances that may potential have an impact on service users health and welfare. EVIDENCE: Records are generally up to date safeguarding the service users’ interests. Service users health and safety is promoted but a number of improvements are required. Health and safety in the home are generally well managed including tests, service and repair to equipment, premises and utilities. There are risk assessments in place, for fire safety, health and safety and staff safety. These are regularly reviewed. The fire system and equipment are routinely tested and serviced. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 20 The gas equipment and installation are certified as safe. The electric has a current safety certificate for installation, and all electrical appliances have been tested. There are records of accidents and incidents maintained at the home giving details of the accident and action taken if a service user has an accident. However the manager did not notify the Commission under Regulation 37 for one service user who had an accident. All incidents or accidents that affect a service users health and welfare must be notified to the Commission For Social Care Inspection The home must complete an annual Quality Assurance that included the service users views to underpin all self-monitoring reviews and development by the home. Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 21 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 X 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 22 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. 1 Standard YA7 Regulation 17(1)(b) 17(2) 17(3) 13(4)(c) 17(!) Schedule 9 13(4)(c) 18(2) 24(1) Requirement Daily records must be available for inspection to demonstrate how the needs of service users are being met. Risk assessments must show how they are monitored, reviewed and managed. All financial records must be accurate and show all transactions. Recruitment must be robust and ensure all the relevant check are completed Supervision of staff must be at least six times per year. A quality Assurance must be completed and show how the views of service users have been incorporated. All accidents and incidents must be reported to The Commission For Social Care inspection on the relevant documentation. Timescale for action 01/04/07 2 3 4 5 6 YA9 YA23 YA23 YA34 YA36 YA39 01/04/07 01/04/07 01/04/07 01/04/07 01/04/07 7 YA42 37(1) a, b, c, d, e, f, g 01/04/07 Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bamville Road (1) DS0000017076.V331027.R01.S.doc Version 5.2 Page 24 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. 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