Inspection on 19/08/05 for 1-3 Adams Street

This inspection was carried out on 19th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 31 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-3 Adams Street 29/05/08

1-3 Adams Street 10/04/07

1-3 Adams Street 05/02/07

1-3 Adams Street 22/11/05

1-3 Adams Street 07/01/05

1-3 Adams Street 25/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1-3 Adams Street West Bromwich West Midlands B70 9TH Lead Inspector Deborah Sharman Unannounced 19 August 2005 th 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 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 Stationary 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. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1-3 Adams Street Address West Bromwich, West Midlands, B70 9TH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 532 6623 0121 505 7808 Pioneer Care Limited Mrs Sandra Horsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th January 2005 Brief Description of the Service: Adam Street is two converted residential dwellings in the heart of a residential area of West Bromwich. The home is close to shops and local amenities, and close to a public transport route. Adam Street provides care for three people with learning disabilities and is owned by Pioneer Care Ltd. The front door can be accessed via a ramp or steps, however there is a large step down to gain access to the front door. The home is set out on two floors providing single bedrooms, one with en-suite space. There are shower and bathing facilities and an office on the first floor, a toilet, two lounges (one smoking) and dining and kitchen facilities on the ground floor. There is car parking on the street, and a front and rear garden. There are no lifts provided within the home and therefore the home may not be suitable for somebody with mobility difficulties. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this unannounced inspection, which began at 10.00am and finished at 6.30pm. Two staff members (one in the morning and one in the afternoon) contributed to the inspection process, as did the newly registered manager who arrived at 11.30am. Service users were out for the majority of the day but the Inspector had the opportunity to speak to a service user towards the end of the day. Documentation was assessed to evidence progress towards meeting previous requirements for improvement. Compliance with a range of national standards was also assessed. The Inspector also toured the environment with the exception of bedrooms as service users were out. What the service does well: What has improved since the last inspection? Since the last inspection the Commission for Social care Inspection has registered a new manager for the home. This manager will be based at the premises as opposed to ‘at arms length’ providing the home with constant and consistent management. Action has been taken to improve service users safety since the last inspection. For example a new fridge has been purchased and its temperatures are now monitored and are compliant minimising the risk of food borne illness. There was no evidence of smoking activity in the office reducing the risk of fire. Wardrobes have been secured to walls reducing the risk of injury to service users. The Adult Protection policy has been improved to ensure that in the event of an incident staff are appropriately guided to act in the best interest of the service user. For service users’ comfort, heating has been provided in the ground floor toilet / shower room. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 6 What they could do better: As at the last inspection, the Inspector arrived to find that staffing levels were not appropriate. There appears to be little improvement in the numbers of staff available or in contingency plans in the event of staff absence. One staff member was found to have worked none stop for 22 hours without sleep. This is clearly compromising the health and safety of the staff member and service users. This same staff member was not being provided with sufficient rest days either. The manager is working 52 hours per week ‘hands on’ with no supernumerary hours to manage the home’s improvement. Support available to the manager is insufficient. The rota remains unacceptably managed. The existence of more than one rota for the same time period provides a lack of clarity and accountability. It was a previous unmet requirement to improve the rota to ensure accuracy. Recruitment processes were again found to be compromising the safety of service users with insufficient checks being carried out prior to appointment. Fire training remains insufficient compromising safety too. Furthermore infection control practice in general must improve. Activity levels for the service user case tracked must improve. It is however recognised that as the home is staffed by one staff member from 10.00am – 4.00pm and often by the manager who has no supernumerary time, service user activity is subsequently not prioritised. The provider must address this. It was recognised during the course of the inspection that the manager and staff require guidance in respect of supporting service users in the community whose behaviour attracts attention from the public. The Inspector noted some issues, which may be preventing this service user from fully accessing the community, and this requires resolution. Compliance with required improvements is slow and must improve. Nine out of forty seven elements of previous requirements assessed have been met. Eighteen new requirements have been made as a result of this inspection. This is not indicative of a progressive home. It is of concern that immediate requirements issued at the last inspection have not been complied with and have unusually been issued for a second time at this inspection. Failure to comply on this occasion will result in the Commission for Social Care Inspection having to seek legal advice about stronger enforcement action. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 7 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. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5. The contract of residence provides the service user with most of the required information and assurance about the rights and responsibilities of both parties. EVIDENCE: (Contracts of residence are in place for service users.) Both the manager of the home and the service users representative had signed the contract for the service user case tracked. The contract includes the fee, the room to be occupied, how care will be provided and the terms and conditions of residency. It is not clear within the contract how regularly the service user plan will be reviewed and the contract is not in an accessible format. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards were not assessed. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,1,5 More able service users take part in valued and fulfilling activities. The home is not planning or providing sufficient activity, community access or family contact for the more dependent service user. EVIDENCE: One service user who is able to come and go from the home independently and at will enjoys doing odd jobs regularly for neighbours within the community. A second service user attends traditional day care full time. The third service user does not attend day care and does not have a structured programme of activity. The staff introduced him to the possibility of attending a drop in centre where a range of suitable activities were offered in June 2005 but he declined. Records of activity outcomes for this service user are not consistently maintained. Activity outcomes for the previous week were assessed for this service user. There was some evidence of him undertaking some domestic tasks but there is a disproportionate emphasis on personal care and ‘relaxing in bedroom’ all day, coming down for tea. Community access for the week assessed was limited to a trip to the supermarket, a walk to a local shop and ‘went out with staff’ to an unknown destination. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 12 The Inspector brought it to the Managers attention that the home should be aiming for a situation where staff accompany the service user to his visit of choice rather that the reverse. There was no evidence of trips to the pub, restaurants, cinema, theatre etc. The manager acknowledged that this is a service user who would grasp all opportunities for activity. The Inspector detected some reluctance on the part of staff to go into the community with this service user through their description of their intention to wear badges in public to help to account for the service users occasional behaviour. No thought had been given to the effect of this on the service users privacy and dignity and it was concluded through discussion that the use of the planned badges was to help the staff feel less awkward in public. Service users are supported to go on holiday twice per year, which exceeds the national minimum standard. The company funds one holiday, which is acceptable. A service user has requested that the annual holiday abroad is brought forward from October to earlier in the year. The manager and staff commented that this would be acceptable as long as it does not interfere with their personal holidays, as they would not want to go away twice in a short period of time. The needs and preferences of the service users must be paramount. Some service users maintain active involvement with family and/or friends. The manager must ensure that arrangements are in place for all service users to maintain this contact, as contact has not been established where relatives are unable to visit the care home. The care plan says ‘maintain links with family by arranging visits or by telephone. Staff must dial the number’. The manager reported some difficulty in obtaining a relative’s new number having only obtained it 3 weeks earlier. In 12 months however the service user had not been taken to visit his close relative. The frequency of contact must be agreed at review and must be included in the plan of care. The manager must review how it evidences contact with family and friends to enable the care plan to be effectively monitored. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These Standards were not assessed. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 In general, service user views are listened to and acted upon. Policies provide generally good guidance to staff to support the protection of service users from neglect and self-harm. Adult protection policy and procedures, in general, protect service users. Recruitment practices compromise the safety of service users from abuse. EVIDENCE: Complaints procedures are in place but staff awareness must be developed in order to implement the procedures. Systems must be in place to better support the receipt and processing of complaints within the home. The home has a complaints policy and procedure. The contact details included for the National Care Standards Commission must be updated to those of the Commission for Social Care Inspection. The timescale set for the resolution of complaints exceeds the expectation of the minimum standard by aiming to resolve complaints within 7 days rather than 28. The policy however does not include reassurance for the complainant that they will not be victimised for making a complaint. The Inspector was informed that the home has not received any complaints. A complaints / comments book must be made available that all staff are aware of. Discussion with staff showed that staff must be supported to ensure that they are aware of the role they must play in bringing to the managers attention any dissatisfaction expressed to them so that appropriate action can be taken. A pictorial complaints procedure is available and accessible to service users within the home. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 15 Policies and procedures are appropriately in place to protect service users. The adult protection policy is comprehensive, the restraint policy makes it clear that restraint is to be a last resort with a focus on de-escalation and must be initially agreed by a multidisciplinary team but states that firm persuasion is allowed. It would be useful to define the boundaries of ‘firm persuasion’. The challenging behaviour policy would also benefit from reference to the context / causes of behaviours that challenge. There are no reported incidents of concern and have been no disciplinary action taken against staff. Service users finances are well managed protecting them from the risk of financial error or abuse. Staff have received adult protection training and were able to verbally define a wide definition of abuse. The manager and staff however must be further supported to know what action to take in the event of an incident or allegation in order to comply with Local Authority guidelines. The Commission for Social Care Inspection is not aware of any incidents, allegations or associated concerns. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 Systems are not sufficient to control the spread of infection or prioritise hygiene within the home. EVIDENCE: Infection control practice requires improvement. The laundry is an open ‘cupboard’ space at the side of the ground floor shower toilet room and is accessed via the kitchen. A risk assessment is not in place to identify and minimise risks arising from this and practice does not minimise risks. For example used incontinence pads that are removed upstairs are carried through the kitchen to dispose in the ground floor shower room. An alternative solution should be sought. Similarly the home has to hand sluice as the washing machine is domestic and not industrial, sluice water is carried through the kitchen unprotected to dispose of outside and the bucket washed using cold water only. This would not effectively cleanse the infected bucket, which is then reintroduced to the premises via the kitchen. The laundry walls are wall papered and therefore not easily cleanable. There is no hand washing facility in the laundry or space for hand washing facilities. The basin in the adjacent toilet room is relied upon but the reality is that this is compromised when the toilet or shower is in use. Personal protective equipment is not available for use in the laundry area. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 Staff are not sufficient in numbers but are appropriately trained. Service users are not supported and protected by the home’s recruitment practices. Service users individual and joint needs are generally met by appropriately trained staff. EVIDENCE: At the inspection on arrival at 9.55a.m, the Inspector found that staffing levels were not sufficient. All service users were at home as the taxi due to take one service user to day care was late. The staff member due to finish his shift at 10.00 a.m. had gone home. One staff member was on duty. This is unacceptable. Inspection showed numerous concerns. The manager who is now the Registered Manager continues to have no supernumerary hours to manager the home and is frequently the sole staff member on duty from 10.00am to 4pm, with responsibility for a service user who does not go out to day care. The rota showed the manager to be working long hours as a carer e.g. 52 hours for the week 15 – 21 July 2005, 47 hours week beginning 22nd July 2005 and 52 hours week beginning 8th August 2005. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 18 The outcome of this for the home is that progress towards meeting outstanding requirements is unacceptable slow. A staff member worked from 4pm on 18 August 2005 until 2pm on 19 August 2005 without sleep having undertaken the waking night shift during this period. This is unsafe. Assessment of the rota showed this staff member to have also had insufficient rest days, compromising the staff members health and service users safety. Staff stated that they are keen to work additional hours but the Manager & Proprietor must ensure that this is on a risk assessed basis so that safety is not compromised. The home must have sufficient staff to manage in these circumstances. It is the Registered Manager’s and the Inspector’s judgement that there are not sufficient staff. A new staff member commenced employment on 12.7.05. A Criminal Record Bureau check had not been received prior to the commencement of employment and at the time of inspection. A POVA first check had not been sent for or received prior to employment and not by the day of this inspection. The Commission for Social Care Inspection had not been informed of any extenuating circumstances requiring his urgent appointment and a risk assessment had not been carried out. In order to immediately protect service users the Registered Manager decided that this staff member should remain away from the premises pending receipt of appropriate documentation. Recruitment practices are not serving to protect service users and the home is in breach of a previous immediate requirement. The Inspector was informed that Learning Disability Award Framework (LDAF) training is in place and that it is being undertaken although there was no evidence available to support this. The Inspector was informed that the new staff member referred to above was ready to commence his LDAF induction training 5 weeks after commencing in employment. Induction training should be completed within 6 weeks of employment. It is pleasing that Equal Opportunity training for the whole staff team has been booked for October 2005. The training records of one staff member were assessed. This staff member has been employed for 2 years and in this time has been provided with nine appropriate training courses. Assessment showed that in the previous 12 months including time to study for NVQ he had been provided with the mandatory 5 days paid training. Fire training however remains insufficient. Fire training was provided in February 2005. However not all staff attended including a high-risk night worker who in 14 months of employment has not received any fire training. The member of staff whose training profile has been case tracked has received fire training twice in a two-year period. He should have received fire training four times within this timescale. This is putting service users and staff at risk. The home has not met the 50 target for staff trained to NVQ level 2 but staff are undertaking the qualification. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 The newly registered manager is not sufficiently supported to run the home and meet its stated purpose, aims and objectives. EVIDENCE: The previous Home Leader has been approved by the Commission for Social Care Inspection as the Registered Manager. This inspection found the manager to be more relaxed and at ease with the inspection process. It is important however now that he is the Registered Manager that he starts to proactively drive the improvements required. He continues to work towards obtaining the required qualification. He is waiting to be issued with a job description that outlines his role and responsibilities. Concerns about the amount of management support available to the home were raised prior to the registration of the new manager as management arrangements were previously at ‘arms length’. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 20 Operational Support records show that in six months from April 2005 the Registered Manager visited the home 3 times which is insufficient. The manager, previously the home leader has not had supervision in 2005 believing his last supervision to have taken place in November 2004. This is insufficient. The manager felt he received support from the staff member appointed to be his ‘deputy’ but this staff member has since left his post and the role has not been replaced. Staff however spoke highly of the manager saying that they find him to be supportive. Maintenance records were assessed and were largely satisfactory (gas / electric / water temperatures). The Inspector remains concerned that thermostatic valves are not fitted to water outlets and is concerned that temperatures could suddenly alter if the combination boiler accessible in the kitchen is accidentally altered. It is an unmet requirement to seek advice about this from the Environmental Health Department. COSHH assessments require updating, as they were in place for most but not all products available within the premises. The fire risk assessment had not been reviewed to reflect a change in risk as a result of a service user reverting to smoking in his bedroom. Fire training is insufficient and the first immediate requirement not fully complied with. The fire alarm system is not wired in and there is no emergency lighting other than battery lights available in every room. The light available for emergency use in the kitchen did not work. The Inspector was told that the West Midlands Fire Service are satisfied with current arrangements. Risk assessments are not in place for the security of the building or to minimise risk from infection; and infection control practice must improve. The fire risk assessment had not been updated to reflect a known change in risk. Risk assessments had not been undertaken following the appointment of staff without the required checks in place to protect service users. The manager did not know that this was required. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 2 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 1 Standard No 11 12 13 14 15 16 17 x 2 2 2 2 x x Standard No 31 32 33 34 35 36 Score x x 1 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1-3 Adams Street Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 22 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 YA1 Regulation 4/5/6 Requirement For pre-existing homes, the statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. At August 2005 Statement of Purpose not available within the home for assessment. Requirement first made October 2003 Review assessment process to incorporate guidance from the National Minimum Standards for Younger Adults – standard 2.3. Produce an admission policy for the home that covers the process of assessments, introduction to the home, admission criteria and procedures. Requirements first made and not met since prior to October 2003 A minimum of three month ‘ settling’ in period of residence must be offered upon the next admission and must be documented in the home’s Timescale for action Not Assessed 31.10.05 2. YA2 14 NOT MET 31.10.05 NOT MET 31.10.05 3. YA5 4,5,16 NOT MET 31.10.05 NOT MET Page 23 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 4. YA10 12(4)(a) 5. YA14 16(2)(m)( n Statement of Purpose, Service User Guide and Terms and Conditions of residency contract. At August 2005 no new Admission and Statement of Purpose not made available for inspection. The terms and conditions of residency contract must be in an appropriate format. Requirement first made and not met since May 2004. The terms and conditions of residency contract must stipulate how regularly care plans will be reviewed. New Requirement at August 2005. The home’s confidentiality policy must be distributed to partner agencies. Evidence of compliance must be retained.Requirement first made May 2004 The manager must ensure that there is a correlation between activity plans, practice, and records of activity. August 05 found no plans and insufficient activity Requirement first made and not met since May 2004. The manager must ensure that all service users are supported to maintain contact with family and friends. The frequency and method of contact with family/friends must be agreed at review, included in the written plan of care, implemented, clearly evidenced to support monitoring the effectiveness of the care plan. Decision-making must be included in the pre admission assessment and subsequent plan of care. E.g. preferred rising and 31.10.05 31.10.05 Not Assessed 31.10.05 NOT MET 31.10.05 6. 7. YA 15 12 31.10.05 8. YA16 14,15 Not Assessed 31.10.05 Page 24 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 9. YA17 10. YA19 12(1)(a) 16(2)(i) 17(1)(a) Sch 3 (3)(m) 171)(a) Sch 3(3)(k) 11. YA19 12/13 12. YA20 13(2) retiring times, management of mail, holidays, daily living decisions, financial decisions, consent to medical intervention, preferred meal times, preferred mode of address etc. Care plans should include decision-making processes required for individual service users. Any limitations must be included in the plan of care. Requirement first made May 04 Nutritional assessments must be undertaken and regularly reviewed for all residents. Requirement first made January 2005 All medical information e.g. weights records and chiropody visits must be recorded individually for each resident. Requirement first made January 2005. Ensure service users have access to regular health care checks e.g. well person clinics. Requirement first made October 2003 Written consent to the administration of medication by the home must be obtained from the relative / representative of residents unable to personally give consent. The manager must undertake a written risk assessment in respect of untrained staff who are administering medication as a result of lone working. Action must be taken to minimise any identified risks. A copy of the written risk assessment must be provided to the Commission for Social Care Inspection by the date set. (Not supplied to C.S.C.I) Requirement first made May 2004 Not Assessed 30.9.05 Not Assessed 31.8.05 Not Assessed 31.10.05 Not Assessed 31.10.05 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 25 13. YA20 13(2) 14. YA20 13 15. YA21 12 16. Ya23 13(6) 17. YA24 16(2)(a)ii Copies of all medication-training certificates (as not available at inspection) must be supplied to the Commission for Social Care Inspection. Requirement first made January 2005. All staff involved in administering medication must receive appropriate training prior to undertaking this task. Requirement first made October 2003 The home’s policy on supporting residents with ageing, illness and death must include the following: · How other service users and staff are supported to deal with the illness or death of a service user. At August 05 policy states service users and staff will be supported but does not indicate how. Requirement first made and not met since May 2004. The Restraint policy must define the boundaries of ‘firm persuasion’ to provide staff with sufficient guidance. The Challenging Behaviour Policy must include a context for the reasons for / causes of behaviour that challenges. The manager and staff must be supported to understand action that they must / must not take in the event of an allegation of abuse. New Requirement at August 2005. The manager must ensure that the home has appropriate facilities for communication by facsimile. Requirement first made and not met since May 2004 Not Assessed Not Assessed 31.10.05 NOT MET 31.10.05 31.10.05 NOT MET 31.10.05 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 26 18. Ya30 13(3) Infection control practices must improve. Personal protective equipment must be provided in the laundry. Hand washing facilities must be provided in the laundry / or the advice of the Infection control nurse sought and acted upon in the absence of hand washing facilities. Laundry walls must be easily cleanable The practice of transporting soiled linen and incontinence pads to the laundry through the kitchen must be reviewed. The practice of carrying sluice water through the kitchen to discard outside must be reviewed. The toilets must be kept clean. A risk assessment that identifies risks of cross contamination must be developed and any risks identified must be minimised seeking the advice of the Infection Control Nurse. New Requirements at August 2005. The policy with respect to the use of volunteers must be reviewed and expanded in relation to recruitment checks undertaken, training provided and the role of volunteers. No Progress at August 2005 Requirement not met since May 2004 The manager must ensure that all staff including night staff receives fire training twice per year and that evidence is 30.9.05 19. YA31 19 PART MET – (training, range of checks, intimate care not included)3 1.10.05 NOT MET Second Immediate Requ’mnt Page 27 20. YA32 23(4)(d) 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 21. YA 33 Ya 42 18 22. YA33 18(1)(a), 37(1)(e) available for inspection. Requirement first made and not met since May 2004 The provider and manager must ensure that staff receive sufficient rest and rest days between shifts. New Requirement at August 2005. Staffing levels must be reviewed using an appropriate tool. A contingency plan for staff absence must be developed and actioned to ensure that in the event of the usual contingency not working that staffing levels can be maintained at all times. This plan must address Adams Streets difficulties in the short and long term. E.g. the use of agency staff may be a shortterm solution pending review and recruitment. Staffing levels must be maintained at all times. A regulation 37 notice must be supplied without delay to the Commission for Social Care Inspection on each future occasion that staffing levels cannot be or have not been maintained. Immediate Requirements first made January 2005. The rota must be accurately maintained at all times and must reflect any changes made. Written confirmation and evidence of staffing (e.g. signed time sheet) must be provided to the Commission for Social Care Inspection in respect of two night shifts - 27th December 2004 and 29th October 2004. issued 19.8.05 Immediate NOT MET Second Immediate Requ’mnt issued 23. YA33 17(2) Sch 4 (7) NOT MET 19.8.05 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 28 24. Ya33 18(1)(a) Requirement first made January 2005. To review staffing numbers and provide the Commission for Social care Inspection with a written plan to increase staff to avoid the outcomes described above. This plan must be provided to the Commission for Social care Inspection by Friday 26 August 2005. New Immediate Requirement at August 2005. Criminal Record Bureau checks must be obtained for new staff prior to the commencement of duties / employment. Requirement first made and not met since May 2004 The registered manager must ensure that all missing items in relation to the recruitment of Mr G as described above are suitably in place and with confirmation provided to the Commission for Social Care Inspection by Friday 14th January 2005 at 4.30pm. The registered manager must ensure that all employment checks are undertaken appropriately and that records are in place and available for inspection prior to the employment of any new staff. Immediate Requirements first made January 2005. All staff should be given a copy of the Home’s disciplinary and grievance procedure, and they should sign to say they have received this. Requirement first made and not met since October 2003. Immediate 25. YA34 19 NOT MET Second Immediate Requ’mnt issued Immediate Requ’mnt met but not by date set (references dated June 05) Immediate requ’mnt not met 26. YA34 19 27. Ya34 18 PART MET - provided but not signed 31.10.05 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 29 28. Ya34 18 29. Ya 34 19 30. Ya34 19 All employment checks as identified in Schedule 2 and 4 of the Care Homes Regulations 2001 must be undertaken prior to the commencement of employment of any staff. All appropriate checks as identified in Schedule 2 of the Care Homes Regulations 2001 for existing staff must be available for the purposes of inspection. Requirement first made and not met since October 2003 The recruitment process must be reviewed to ensure clear lines of communication between the centralised personnel function and the Registered Manager to ensure a more effective and accountable recruitment process that adequately protects service users. New Requirement at August 2005 To ensure that all recruitment checks and documentation as per Schedule 2 are in place prior to the employment of new staff at the next appointment. To take immediate action to safeguard service users. To confirm action taken in writing to the Commission for Social care Inspection by Monday 22 August 2005 at 5pm and to confirm in writing by this time action that will be taken in future to ensure compliance. New Immediate Requirement at August 2005. All new staff must receive structured induction training to Sector Skills Councils Specifications. NOT MET Second Immediate Requ’ment issued 31.10.05 Immediate 31. YA35 18(1)(c) No evidence available next Page 30 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 32. YA35 18(1)(a) Requirement first made May 2004 The manager must provide an action plan to the Commission for Social Care Inspection outlining how the NVQ target for 2005 will be met – At August 2005 target not met. Requirement first made January 2005. Management support /contact/visits must be better evidenced Requirement first made January 2005. Adequate supernumerary time must be given to the homeleader and assistant homeleader to enable monitoring and development of systems. To forward a copy of the Registered Manager’s job description to the inspector once it has been reviewed. The registered manager must continue to provide support until such a time as the National Care Standards Commission approves a new manager. Requirements first made and not met since October 2003 The provider must issue the new Registered Manager with a Job description. New Requirement at August 2005. The newly Registered Manager must be provided with formal supervision six times per year as a minimum. New Requirement at August 05 Develop an effective quality inspection Not Assessed 31.10.05 33. YA37 8 NOT MET 30.9.05 34. Ya37 18 NOT MET 31.10.05 Not Met 31.10.05 Not Met Insufficient contact - 35. YA37 18 30.9.05 36. Ya37 9 Aug05 Aug 06 37. YA39 24 NOT Page 31 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 monitoring system. Ensure that the quality assurance system seeks views of stakeholders and staff. Publish results of service user surveys and ensure they are made available to service users, their representatives and other interested parties including the National Care Standards Commission. Action must be progressed within timescales to implement requirements from National Care Standards Commission inspection reports. Requirements first made and not met since prior to October 2003. The manager must ensure that the home’s physical Intervention policy is reviewed to ensure compliance with the Department of Health Guidelines and the British Institute of Learning Disabilities Code of Practice. ASSESSED 31.12.05 38. YA40 13(6) Not Met 31.12.05 39. YA42 23(4)(c) Requirement first made and not met since May 2004 Advice from the Environmental NOT MET Heath Department must be 31.9.05 sought in relation to the monitoring of water temperatures from a combination boiler. Risk assessment to be undertaken in the meantime and strategies implemented to reduce risk. (Can now adjust water temperature but no thermostatic valves/ Environmental Health not consulted) The manager must ensure that all risk associated with lone working are identified and managed appropriately. NOT MET 31.8.05 Page 32 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 40. YA42 23(4)(d)( e) Requirement first made and not met since May 2004 Fire training must be booked for all staff by Friday 14th January 2005 and / or evidence of recent completion must be provided to the Commission for Social Care Inspection by this same date. Notification to the Commission for Social Care Inspection must include the date booked for fire training. Immediate Requ’mnt not met second immediate requ’mnt issued All staff must receive fire training twice per year from Pioneer Care Not Met 19.8.05 irrespective of training received elsewhere as provided by other employers and records must be available for inspection. Immediate Requirements first made January 2005. A detailed written fire risk assessment must be undertaken in line with advice from the West Midlands Fire Service including all known variables / risks / considerations. Action must be taken to control any identified risks. This must be kept under close review and amended as risks / circumstances change. A copy of the developed fire risk assessment must be supplied to the Commission for Social Care Inspection by Friday 14th January 2004 at 4.30 pm. Immediate Requirement first made January 2005. To ensure sufficient fire training for all staff (twice per year) including J .G. To write to the Commission for Social Care Inspection by Monday 22 August 41. YA42 23(4)(a) Immediate Req PART MET – changes not reviewed. Second immediate requ’mnt issued. 42. 42, 24, 35 23(4)(d)( e) 23(4)(a) Immediate 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 33 2005 at 5pm to confirm the date of the fire training and the names of staff booked to attend. To review the Fire Risk assessment and take action to minimise any risks identified forwarding a copy to the Commission for Social Care Inspection by Monday 22 August 2005 at 5pm. New Immediate Requirements at August 2005 The Manager must update the 30.9.05 COSHH assessments to reflect all the chemicals held on the premises. New Requirement at August 2005 Records of Fire Drills must detail the names of those people taking part. New Requirement at August 2005 The manager is to provide the Commission for Social Care Inspection with written confirmation that the home’s insurance cover complies with all elements of National Minimum Standards 43.4 and 43.5 Requirement first made May 2004. Ensure accounts and financial plans are available for inspection. (Business plan seen) Requirement first made prior to October 2003. 43. Ya42 13(4) 44. Ya42 23 30.9.05 45. YA43 25(2)(e) Not Assessed 31.10.05 46. YA43 17(2)/25 NOT MET 31.10.05 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 34 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. 2. Refer to Standard YA37 YA8 Good Practice Recommendations Manager to obtain qualification identified in National Minimum Standards for Younger Adults. Involve service users in reviewing the policies and procedures. 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 35 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8DA 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 1-3 Adams Street E55 S4806 1-3 Adams Street V233501 190805 Stg 4.doc Version 1.40 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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