DOMICILIARY CARE AGENCY Edgbaston Beaumont Domiciliary Care Agency 32 St James Road Edgbaston Birmingham West Midlands B15 2NX Lead Inspector Yvonne Reay Key Unannounced Inspection 19 August 2006 10:00 Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.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 Inspection Report Author CSCI Audience General Public Further copies from 0870 240 7535 (telephone order line) Copyright 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 Internet address www.csci.org.uk Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.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 agency are those for Domiciliary Care. 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. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 3
SERVICE INFORMATION Name of service Edgbaston Beaumont Domiciliary Care Agency Address 32 St James Road Edgbaston Birmingham West Midlands B15 2NX Telephone number 0121 440 0421 Fax number 0121 446 3333 Email address edgbaston@barchester.net Provider Web address Name of registered provider(s)/company (if applicable) Westminster Health Care (UK) Ltd. Name of registered manager (if applicable) Type of registration Domiciliary Care Agencies Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 4
SERVICE INFORMATION Conditions of registration: Date of last inspection First Inspection since registration. Brief Description of the Service: The Agency is run from Care Home premises situated in a suburb of Birmingham close to the city centre and with easy access to local amenities and public transport. There is ample parking at the front of the premises. The Domiciliary Care service (Close Care) is provided for residents in 3 apartments in the main building and a number of bungalows in the grounds of the Home. These properties are privately owned and owners are able to purchase packages of care according to need. The apartments and bungalows are linked to the home s emergency call system and residents can access the Homes facilities for example meals (at an extra cost) and activities (no charge). The service is managed from the care homes management and administrative offices. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 5
SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection was the first since the Agency registered. The Manager, who is responsible for both the Care Home and the Domiciliary Service, was present throughout. She is currently applying to CSCI to be the Registered Manager for both services. The Agency currently provides personal care for one Service User only who was interviewed along with her husband. Records and documents were inspected and staff and management were also interviewed. The Agency is currently registered as a large agency. Consideration should be given to vary the registration to that of a small agency. What the service does well: The Service Users needs were laid out in a plan of care. The one Service User who is currently receiving personal care is treated with dignity and respect. Her husband stated that Staff quality is good and I have no problems there, staff are polite and respectful. Service Users are protected by the Home s policies and practices in medication administration, Health and Safety, and Adult Protection. The Agency has a good training and development programme in place and the Induction process appeared to be thorough. One member of staff commented that I like working here and I feel supported. We have handovers and team meetings A complaints procedure is in place and there have been no complaints received by the Agency since registration. The Manager is experienced in care of the elderly and is also a Registered Nurse. She also holds a Certificate in Management and NVQ level 4. What has improved since the last inspection? This is the Agency s first inspection since registration. What they could do better: The service is not always consistent for the one Service User currently receiving a personal care service. Her husband indicated that there could be at times a lack of continuity of staff delivering care. It would be beneficial if the supervision programme were streamlined in order to demonstrate full compliance with this standard. Supervision is being carried out but not always recorded. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.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. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 7
DETAILS OF INSPECTOR FINDINGS CONTENTS User Focused Services (Standards 1 6) Personal Care (Standards 7-10) Protection (Standards 11-16) Managers and Staff (Standards 17-21) Organisation and Running of the business (Standards 22-27) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 8
User Focused Services The intended outcomes for Standards 1 6 are: 1. Current and potential service users and their relatives have access to comprehensive information, so that they can make informed decisions on whether the agency is able to meet their specific care needs. 2. The care needs requirements of service users and their personal or family carers when appropriate, are individually assessed before they are offered a personal domiciliary care service. 3. Service users, their relatives and representatives know that the agency providing their care service has the skills and competence required to meet their care needs. 4. Each service user has a written individual service contract or equivalent for the provision of care, with the agency, except employment agencies solely introducing workers. 5. Service users and their relatives or representatives know that their personal information is handled appropriately and that their personal confidences are respected. In the case of standards 5.2 and 5.3, these do not apply to employment agencies solely introducing workers. 6. Service users receive a flexible, consistent and reliable personal care service. In the case of standards 6.3 and 6.4 these do not apply to employment agencies solely introducing workers. The Commission considers Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 2 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The care needs of Service Users are fully assessed before being accepted as suitable for a Domiciliary Care service. The service is not always consistent for the one Service User currently receiving personal care. EVIDENCE: The majority of Service Users are self-funded and the Manager carries out all assessments prior to offering a Domiciliary Care service. The service is not always consistent for the one Service User currently receiving personal care. Her husband did state however that this was not a particular problem for his wife and staff do respond flexibly to her needs in particular when getting up in the mornings. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 9
Staff are rostered in on the care home duty rota and once on duty are allocated to Close Care. They subsequently have other responsibilities on any particular shift with residents of the care home. This matter was discussed with the Manager who explained that there was a core group of staff assigned to this Service User but one of the main carers had been on vacation. Domiciliary Care and support should be provided in such a way as to meet individual needs where possible and provide a user focussed service. It is an expectation that within reason staff arrive at the Service User within the time bad specified and the Manager ensures continuity of staff were possible. Should the service develop to provide personal care to a number of Service Users consideration will need to be given to this current model of staff allocation in order too ensure the care needs of those Service Users receiving a Domiciliary Care service are met in full. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 10
Personal Care The intended outcomes for Standard 7 10 are: 7. The care needs, wishes, preferences and personal goals for each individual service user are recorded in their personal service user plan, except for employment agencies solely introducing workers. 8. Service users feel that they are treated with respect and valued as a person, and their right to privacy is upheld. 9. Service users are assisted to make their own decisions and control their own lives and are supported in maintaining their independence. 10. The agency s policy and procedures on medication and health related activities protect service users and assists them to maintain responsibility for their own medication and to remain in their own home, even if they are unable to administer their medication themselves. In the case of standards 10.8 and 10.9, these do not apply to employment agencies solely introducing workers. The Commission considers Standards 8 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 7,8, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Service Users needs were laid out in a plan of care and the one Service User currently receiving personal care is treated with dignity and respect. Service Users are protected by the home s policies and practices in medication administration. EVIDENCE: The Agency currently provides personal care for on Service User only. This Service Users husband stated that: Staff quality is good and I have no problems there, staff are polite and respectful The care plan for this person was inspected and was seen to cover most of the required areas in order for staff to be able to deliver appropriate care. However it was suggested more attention be given to detail in particular her social needs and preferences and to reflect a more holistic overview of her needs. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 11
The Service User had a medication plan in place and a record sheet for recording medication assisted with. Registered Nurses who work at the Care Home assist with this Service Users medication. The Manager informed the Inspector that all staff have all had training in medication management. Whilst interviewing staff it became apparent that one Service User who is currently receiving a domestic service only does in fact receive personal care (a morning shower) however the Manager was unaware of this. The Manager must ensure staff are fully aware of their responsibilities to report any change in the needs of the Service User in order for a full review of care to be carried out. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 12
Protection The intended outcomes for Standards 11-16 are: 11. The health, safety and welfare of service users and care and support staff is promoted and protected, except for employment agencies solely introducing workers. 12. The risk of accidents and harm happening to Service Users and staff in the provision of the personal care, is minimised, except for employment agencies solely introducing workers. 13. The money and property of service users is protected at all times whilst providing the care service, except for employment agencies solely introducing workers. 14. Service users are protected from abuse, neglect and self-harm, except for employment agencies solely introducing workers. 15. Service users are protected and are safe in their home, except for employment agencies solely introducing workers. 16. The health, rights and best interests of service users are safeguarded by maintaining a record of key events and activities undertaken in the home in relation to the provision of personal care, except for employment agencies solely introducing workers. The Commission considers Standards 11, 12 and 14 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 11,12 and 14 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service Users are protected by the Home s policies and practices in Health and Safety. Service Users are protected from abuse. EVIDENCE: The Manager is responsible for safety audits and the frequency of these checks are directed by the organisation. These audits cover all areas of Health and Safety in particular smoke alarms, fire points, nurse call systems in all Close are apartments and bungalows. The organisation carries out an annual Health and Safety audit and includes all the property under the Close Care provision. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 13
There have been no allegations of Abuse since the Agency registered and staff had received POVA Training. The Agency has a policy for Adult Protection. The one Service User receiving personal care had a manual handling and medication risk assessment in place. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 14
Managers and Staff The intended outcomes for Standards 17-21 are: 17. The well-being, health and security of services users is protected by the agency s policies and procedures on recruitment and selection of staff. 18. Service users benefit from clarity of staff roles and responsibilities, except for employment agencies solely introducing workers. 19. Service users know that staff are appropriately trained to meet their personal care needs, except for employment agencies solely introducing workers. 20. The personal care of service users is provided by qualified and competent staff, except for employment agencies solely introducing workers. 21. Service users know and benefit from having staff who are supervised and whose performance is appraised regularly, except for employment agencies solely introducing workers. The Commission considers Standards 17, 19 and 21 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 17,19 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff personnel files mostly contained the required information in order to protect Service Users. The Agency has a good training and development programme in place. The Supervision programme should be streamlined in order to demonstrate full compliance with this standard. EVIDENCE: The quality of record keeping on staff files inspected was satisfactory and files mostly contained the required information in order to protect Service Users. All staff had a CRB check carried out however one file did only have one written reference in place. There was a supervision schedule in place and staff are mostly being supervised and appraised. The Manager holds group meetings for staff, which are included in the supervision programme and staff are supervised whilst delivering care to Service Users but this is not always being recorded. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 15
It would be beneficial if the Supervision programme were streamlined in order to demonstrate full compliance with this standard. Supervision is being carried out but not always recorded. The Agency has a good training and development programme in place and the Induction process appeared to be thorough. The new induction process is currently being implemented and some records were incomplete for example one carer had no final assessment recorded following her induction. Two staff were interviewed and one commented that: I like working here and I feel supported. We have handovers and team meetings Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 16
Organisation and Running of the Business The intended outcomes for Standards 22 27 are: 22. Service users receive a consistent, well managed and planned service. 23. The continuity of the service provided to service users is safeguarded by the accounting and financial procedures of the agency. 24. The rights and best interests of service users are safeguarded by the agency keeping accurate and up-to-date records. 25. The service user s rights, health, and best interests are safeguarded by robust policies and procedures which are consistently implemented and constantly monitored by the agency. 26. Service users and their relatives or representatives are confident that their complaints will be listened to, taken seriously and acted upon. 27. The service is run in the best interests of its service users. The Commission considers Standards 22 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT we looked at outcomes for the following standard(s): 22 26 and 27 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service Users are protected by the Agency s procedure for complaints and receive a well-managed service. EVIDENCE: The Manager is responsible for both the Care Home and the Domiciliary Care service. Whilst this is her first experience of managing a Domiciliary Care service she is an experienced manager in elderly care and a Registered Nurse. She also holds a Certificate in Management and NVQ level 4.The inspector was informed that sufficient management support is provided by the organisation to enable her to carry out her job. She is currently in the process of submitting an application to register with CSCI to be the Registered Manager for both services. The organisation sends out an annual survey to a number of Service Users who are selected randomly. It was suggested that the organisation carries out separate surveys for the Care Home and the Domiciliary Service. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 17
Meetings are held twice yearly with the Close Care Service Users and the Manager informed the Inspector that she regularly has individual meetings with them but these meetings are not minuted. Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 18
SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Domiciliary Care have been met and uses the following scale. 4 Standard Exceeded (Commendable) 3 Standard Met (No Shortfalls) 2 Standard Almost Met (Minor Shortfalls) 1 Standard Not Met (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 User Focused Services Managers and Staff Standard No Score Standard No Score 1 X 17 2 2 3 18 X 3 X 19 2 4 X 20 X 5 X 21 2 6 2 Personal Care Organisation And Running Of The Business Standard No Score Standard No Score 7 3 22 3 8 3 23 X 9 X 24 X 10 3 25 X Protection Standard No Score 11 3 12 3 13 X 14 3 15 X 16 x 26 3 27 3 Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 19
Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Domiciliary Care Regulations 2002 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1 DO17 12 The Registered Person must 30/09/06 Schedule 3 (5) ensure that two written references are on file for all staff. 2 DO19 15(2)(a) The Registered Person must 30/09/06 ensure that records support a full and robust induction process for all new staff. 3 DO21 15(4) The Registered Person must 31/10/06 ensure that records support a programme of supervision. 4 DO6 14(4) The Registered Person must 30/09/06 ensure that Service Users receive a consistent service at all times. 5 DO22 8 An application must be submitted to register the Manager with CSCI. 30/09/06 Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 20
RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 21
Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Edgbaston Beaumont Domiciliary Care Agency DS0000054694.V300979.R01.S.doc Version 5.2 Page 22