Inspection on 22/11/05 for 1-3 Adams Street

This inspection was carried out on 22nd November 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 29 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 19/08/05

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 Debbie Sharman Announced Inspection 22nd November 2005 09:30 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 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 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 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. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 1-3 Adams Street Address West Bromwich West Midlands B70 9TH 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) 0121 532 6623 0121 505 7808 Pioneer Care Limited Neville Thompson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One male - DE(E) Date of last inspection 19 August 2005 Brief Description of the Service: Adam Street has been built from 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 DS0000004806.V256149.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection meaning that prior notification of the inspection date was given to the proprietor and manager. One Inspector conducted the inspection. The inspection started at 9.30 a.m. and finished at 4.30p.m. The Area Manager and the registered manager who were present throughout the day supported the inspection process. Staff on duty were also present and contributed to the inspection. The Inspector was able to interview a service user and a second service user showed the Inspector his bedroom. Documentation was also assessed and the premises were inspected. The plan for this inspection was to assess those core standards that were not assessed at the previous inspection. The plan was to also assess progress made since the last inspection towards requirements previously issued to ensure improvements assessed as needed. Significant progress was evident. Many previous requirements have been fully met and have therefore been deleted from this report. Four new requirements have arisen from this inspection and are included in the requirement list. What the service does well: Adam Street is small, homely and domestic in style and smells fresh throughout. Service users are treated with respect. There is a high proportion of male staff, which is important, as all service users are male. The provider has responded well to constructive criticism contained within the previous report and has provided the resources to ensure improvement. Service users are happy and their views are listened to. One service user who showed the Inspector his bedroom was clearly delighted with it. A second service user liked the improvements to the premises. This service user said that he was happy, that the staff are nice and that the dinners are ‘lovely and smashing’. He said that he feels safe at Adams Street, confirmed his appointments with the dentist and chiropodist and said that he is able to choose when he goes to bed. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Service users have keys to the front door and to their bedrooms which is good practice. However current locks do not limit risk should access be required quickly by staff or the emergency services. Locks must be changed. Windows have not been risk assessed and some windows require restricting to secure the building. Some aspects of care plans require improvement for example nutritional risk assessments must be reviewed more frequently and preferred routines of service users need to be detailed. Greater clarity in line with acceptable techniques is required in respect of behaviour management guidance. Care plans that refer to routine health screening must be quantified e.g. how often are dental, chiropody etc appointments required? The outcomes of all health appointments must be recorded. Medication is generally well managed but there were two gaps in the medication administration record so it is not known whether the service user received those prescribed doses. It is essential that there is a system in place that alerts staff and the manager to potential errors so they can be investigated and appropriate action taken to safeguard the service users health. The manager must develop and implement regular medication competency assessments to complement medication training provided for staff. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 7 This will give greater assurance of staffs ongoing competency to administer medication. Infection control systems have improved. However alcohol scrub obtained to use as a hand wash in the absence of water in the laundry had been purchased but was not accessible and therefore was not being used. The difficulty in respect of this is where in such a limited space it could safely but accessibly be stored. This must be satisfactorily resolved so that staff can use it to control the risk of infection. 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 DS0000004806.V256149.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. Standard 2 was due for assessment but was not as there have been no new service users admitted to the home. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 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 the following standard(s): 6, 7, 9 Care plans are in place and generally identify how service users needs are to be met with some areas identified for improvement. There is evidence that service users make decisions about their lives. Service users are supported to take risks and systems are generally in place to minimise most risks identified. EVIDENCE: Each service user has a care plan which is now logically sequenced and based upon the homes assessment including risk assessment of the service user. (A new assessment pro forma has been designed). Health care plans are in place but do not specify how often appointments are required. Communication / behaviour care plans are also in place but require some review to ensure that there is sufficient guidance about known triggers / diffusion techniques etc. Currently the plan states ‘put (the service user) in a place of safety i.e. bedroom’ which does not protect the service user from potentially unwarranted / unsafe restraint. Manager’s knowledge was sufficient but this was not reflected in the written guidance for staff. Preferred routines have not been included in the plan of care but the managers were aware of the need to do this. Those service users who are able to have signed their own care plans 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 11 indicating knowledge and agreement. Reviews are held six monthly, with records signed again by service users who are able to. Letters have been sent to service users following review to state that the home can continue to meet the service users needs. This is good practice. Reviews have also been held with the placing Social Worker for the service user who moved in most recently. There was sufficient evidence (tenants meetings, diary records and talking to service users) to demonstrate that staff respect service users right to make decisions. Risk assessments account for any restrictions to this. Decisions taken by service users range from changes to money management, bed times, activities and involvement in choosing the paint and flooring for the redecoration. Service users who are able have a high degree of autonomy. Recorded preferred routines would better support service users and assessment of whether this is being fully met but this inspection showed outcomes for service users to be good. The Inspector was informed that the visiting Environmental Health Officer saw risk assessments in September 2005 and deemed them to be satisfactory. Risk assessments support the care plans. A range of risk assessments was in place for the service user case tracked including access to the community, choking, toileting, personal care etc. Nutritional risk assessments are in place but need to be reviewed more often to account for any changes. For example for the service user case tracked the nutritional risk assessment was last reviewed in March 2005 but the service user has steadily lost weight since April 2005 with no action taken. There is no system in place to indicate clinically accepted safe weight ranges for service users therefore the urgency or otherwise of action required is not known. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 16, 17 Service users rights are respected and responsibilities recognised in their daily lives. Meals are provided that meet with service users expressed preferences. The home is not evidencing that nutritional need is being met as this is not fully assessed or planned for. EVIDENCE: Outcomes for service users are good in respect of daily house rules and routines. Able service users come and go at will. The service user whom the Inspector spoke to said that he chooses what time to go to bed and get up in the morning. Service users have their own keys (although locks must be changed to enable staff access in an emergency). Staff interact naturally with service users. There is scope to assess and therefore plan for the management of service users mail on the newly designed needs assessment proforma but this has not yet been implemented. Service users have unrestricted access to the home and grounds and at this inspection there was good evidence of family contact for the service user case tracked. Housekeeping tasks are also, where relevant, specified in the plan of care. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 13 The diary records of shifts show service users to be undertaking some household tasks because they want to. Preferred routines are not yet recorded. This will provide a baseline against which to assess the performance of the home. However at this inspection it is judged that outcomes for service users are good. A service user said that the meals are ‘smashing’ and said that he is provided with his favourite meals. Staff are recording meals that service users eat and the records seen evidence variety and that individual choices are respected and provided for. Menus are not available which does not demonstrate forward planning to meet dietary need, as dietary needs have not been assessed. Nutritional need must be more regularly assessed and action taken where identified. Weight records however have improved. Service users contribute to preparing meals, which are pleasant, and at flexible times. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 18, 19, 20 Service users receive personal care in the way they prefer and require. Service users physical and emotional health needs are met with some areas for improvement in care planning identified. Medication is generally administered well and generally protects service users. The implementation of a system to alert staff and managers to potential errors in medication will better protect service users. EVIDENCE: All service users are male and are fully mobile with nobody requiring support with mobilising. No disability aids or equipment is required. Gender issues are addressed in service users plans of care and the majority of carers are male. Routines are flexible with outcomes good for service users although service users preferences are not yet accounted for in plans of care. Care plans contain good detail to guide staff with the provision of personal care. The care plan of one service user case tracked includes detail in respect of toileting, bathing, dressing, washing, shaving, hair and oral care. A service users continence care is also appropriately provided throughout the night ensuring his ability to self-care and promotes his dignity without resorting to incontinence pads. A service user spoken to indicated that staff respect his privacy during the provision of personal care. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 15 Health outcomes for the service user case tracked are good with evidence of up to date screening visits to the chiropodist three times, dentist twice and a hearing and eye test in November and October 2005 respectively. A ‘well man’ video has been obtained to help provide service users gain knowledge about men’s health issues. The manager said that he took service users to the GP for testicular screening, which was provided but not evidenced in the homes health records. Care planning could improve by ensuring that the regularity of health screening is specified and that testicular screening is included in a plan of care. It is important too that all health appointments are fully documented including their outcomes and that any changes are adjusted in the plan of care. For example the care plan for the service user case tracked states that the service user has a condition that requires prescription but this is no longer the case. Care plans recognise the potential for frustration from inability to communicate but guidance could be more detailed in respect of communication and the potential for associated behaviours. A good care plan is in place to reduce the risk of abrasions to the service users feet, which had been subject to medical advice. Service users except in an emergency consult the Doctor at the Doctors surgery. The medication policy has been reviewed in July 2005 and now provides better guidance to staff and managers. Although it does not include that medications must be retained for seven days in the event of death. Records are safely stored, there are no controlled drugs and no-one self-medicates. Storage does not include excess stock, which minimises risk and waste. Records are kept of medicines delivered to the home and administered. Administration records were generally well maintained with the exception of two gaps, which had not been investigated. There is a system to record medication that is returned to the pharmacist but returns are infrequently needed. The supplying pharmacist visits the home quarterly to check practice and to provide advice. The pharmacist has issued a caution to the manager about the effect on a service user of swallowing prescribed mouthwash. He continues to swallow the mouthwash, which is detrimental to his health. This must be reviewed with the GP. Staff are not signing for the administration of the mouthwash, which is prescribed and included on the pre printed medication administration record. Some staff have done accredited medication training and others have undertaken an alternative medication course whilst awaiting the availability of accredited training. The manager must ensure that medication records are audited and that a system is implemented to alert staff and management to the possibility of none administration so remedial action can be taken without delay. The manager must also ensure the ongoing competence of his staff to administer and manage medication. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 16 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 the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Service users live in a homely, comfortable and generally safe environment. Inappropriate bedroom door locks and absence of window restrictors provides some risk to service users. EVIDENCE: The premises are warm and comfortable, airy, clean and fresh smelling. The home offers access to local amenities and the home has its own transport. Furnishings are domestic and unobtrusive. The Fire Service last visited in 2002 and the Environmental Health Department last visited recently in September 2005 looking at risk assessment, COSHH management and provided advice about legionella and Infection control. Since the last inspection the home has undergone extensive redecoration providing a more pleasant living environment for service users. The hall and stairs, lounge, dining room, upstairs bathroom and a service users bedroom have been painted. Laminate flooring has been laid on the ground floor and in a service users bedroom as per the recorded wishes of one service user. There are plans too to replace the kitchen flooring. The kitchen has been refitted and new tiling in the kitchen is in process. The downstairs shower room has a new cupboard and has been retiled providing a more inviting and clean personal space. A new washing machine has been provided and although infection 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 18 control advice was to paint the laundry area, the provider has decided to tile this area too to ensure a surface that is easier to keep clean. Infection control systems have also improved. The refurbishments have provided a clean and easier to keep clean area. Gloves and aprons were available and sluicing practice has changed based upon advice sought and received. Staff must use alcohol scrub obtained to disinfect hands in the absence of water in the laundry area. It was not accessible to staff due to safe storage difficulties. One service user asked the Inspector to view his room. He was clearly delighted with it. It was well furnished, neat and the ensuite very clean. Another service user spoken to offered the Inspector the information that he liked the improvements to the premises especially the flooring and said that he had everything in his room that he needs. Locks on service users bedrooms must be changed, as they do not allow ease of access for staff in the event of an emergency. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not fully assessed. However it was noted that the staff rota is now understandable which is a significant improvement since the last inspection. Staff have indicated in writing that they wish to undertake additional shifts but the rota, which includes a new staff member due to start in two weeks time, is providing most staff with more regular rest days. The rota still shows that one staff member between November and December will have worked for 22 days without a break. This, the inspector was told, is his choice. A written statement has been obtained from staff stating their wish to undertake long hours but this does not constitute a risk assessment, as the risk will be different for each staff member. The provider however said they are beginning to monitor the effect of the hours on staff through supervision and this must be brought together in a formal individualised assessment of risk. Staff are now rostered to stay at work until 11am instead of 10.00am to avoid the risk of the home being understaffed in the event of day care transport being late to pick service users up. A new contingency plan is also in place to support the manager and staff in the event of staff phoning in sick at the last minute. A list of staff within the company who are willing to work additional 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 20 shifts is now available with their contact telephone numbers. The manager must ensure that these staff are fit to work and have received appropriate rests between shifts. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42. The provider is beginning to develop a quality assurance tool underpinned by service user and third party feedback. Systems to promote the health, safety and welfare of service users has significantly improved and service users are now better protected. EVIDENCE: The provider is beginning to seek formal feedback from family, service users and professional visitors about the service it provides and has had some responses. The completed questionnaires seen by the Inspector indicate a high level of satisfaction with the service provided. The provider intends to survey staff next and upon receipt of responses will collate and publish all of the results. Prior to this inspection the Commission for Social care Inspection provided comments cards, which were completed by 2 service users and 2 relatives again indicating high levels of satisfaction. Service users had been told of this 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 22 announced inspection as service users were clearly expecting the Inspector upon arrival. Service user and other interested parties feedback is a significant part of quality assurance but it is one element. The provider must now expand its quality assurance to ensure continuous self-monitoring, using an objective, consistently obtained and reviewed verifiable method, ensuring that an internal audit takes place at least annually. This is not yet in place but progress is being made. Maintenance documentation was assessed at the previous inspection. Training programmes are in place to ensure that staff receive training in key areas. All staff have first aid training, most have infection control training with one place booked for a remaining staff member. Bookings have been made for those staff without moving and handling training. Four staff were due to do Moving and Handling training the week of the inspection. All staff have undertaken Food Hygiene training. COSHH assessments have all been reviewed with up to date guidance provided to staff to ensure that only those products are bought that have been assessed. The Inspector was told that reassurances have been received that the water from the combination boiler is effectively regulated. The Fire risk assessment has been reviewed and action has been taken to minimise assessed risk e.g. curtains and bedding in a smokers bedroom have been treated. The service user who smokes told the Inspector that it is not safe for him to smoke in his bedroom and is against the rules. The previous requirement to increase levels of fire training for staff has been met, better preparing staff for action in the event of a fire. Health and Safety information has been produced in widget form for service users but discussion highlighted that this format is not entirely appropriate for service users at Adam Street. Windows have not been risk assessed and some vulnerable windows are not restricted. The area manager agreed to ensure that this is addressed without delay along with the provision of bedroom door locks that protect the service users privacy but can be accessed by staff in the event of an emergency. The risk assessment for the environment was reviewed in September 2005 and has been further adapted the Inspector was told to include recommendations made by the visiting Environmental Health Officer. The provider has received updated Learning Disability Award Framework Induction packs for new staff to work through. Some previous new staff have 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 23 not undertaken a full and appropriate induction due to the wait incurred in obtaining the new programme of training. It is planned that staff will now do this. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 24 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 x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1-3 Adams Street Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000004806.V256149.R01.S.doc Version 5.0 Page 25 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 Not assessed November 2005. Produce an admission policy for the home that covers the process of assessments, introduction to the home, admission criteria and procedures. Requirements first before October 2003 Part Met at November 2005. Timescale for action 31/01/06 2 YA2 14 31/01/06 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 26 3 YA6 13(6) 15 Care plans must include revised and improved procedures for the behaviour management of service users focussing on positive behaviour, ability and willingness in line with DOH and BILD guidelines. 31/12/05 4 YA14 New Requirement at November 2005. 16(2)(m)(n 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 May 2004. Not Assessed at November 2005. 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. Requirement first made August 2005. Not assessed at November 2005. Care plans must include decision-making processes required for individual service users. Requirement first made May 04 31/12/05 5 YA15 12 31/12/05 6 YA16 14, 15 31/12/05 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 27 7 YA17 12(1)(a) 16(2)(i) Nutritional assessments must be 31/12/05 undertaken and regularly reviewed for all residents. Requirement first made January 2005 Part Met at November 2005 undertaken but not regularly reviewed. All medical information e.g. weights records and chiropody visits must be recorded individually for each resident. Requirement first made January 2005. Testicular screening appointment not recorded at November 2005. Ensure service users have access to regular health care checks e.g. well person clinics. Requirement first made October 2003 Not evidenced at November 2005 - but improvement in other health records. All staff involved in administering medication must receive appropriate training prior to undertaking this task. Requirement first made October 2003 At November 2005 part met - 2 staff still to do accredited training. The manager must regularly audit the medication / medication records and must investigate with written outcomes any findings and action taken. DS0000004806.V256149.R01.S.doc 8 YA19 17(1)(a) Sch 3(3)(k) 30/11/05 9 YA19 12, 13 31/12/05 10 YA20 13 31/01/06 11 YA20 13 31/12/05 1-3 Adams Street Version 5.0 Page 28 The manager must ensure that a system is implemented to ensure that errors / gaps are identified, investigated and remedial action where necessary taken without delay and with medical advice. Any errors found must be reported as reg 37 to CSCI. New Requirements at November 2005. The manager must ensure that the prescribed mouthwash is reviewed with the service users GP. New Requirement November 2005. 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 May 2004. The manager must ensure that the home has appropriate facilities for communication by facsimile. Requirement first made and not met since May 2004 12 YA20 13 30/11/05 13 YA21 12 31/01/06 14 YA24 16(2)(a)ii 31/01/05 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 29 15 YA30 13(3) Hand washing facilities must be provided in the laundry At November 2005 alcohol hand scrub purchased not made available. 22/11/05 16 YA31 19 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 At November 2005 - detail is not sufficiently specific e.g. rigorous checks The provider and manager must ensure that staff receive sufficient rest and rest days between shifts. New Requirement at August 2005. At November 2005 some progress but to keep under review. Working hours must be formally risk assessed for each staff member. New Requirement at November 2005 31/01/06 17 YA33 18 31/12/05 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 30 18 YA34 19 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 NOT MET at Aug 05 Second Immediate Requ’mnt issued Not Assesed at November 2005 - no new staff. 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 Not Assessed at November 2005 - no new staff. 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. Requirement first made October 2003 NOT MET at August 2005 Second Immediate Requ’ment issued Not Assessed at November 2005 - no new staff. 22/11/05 19 YA34 19 22/11/05 20 YA34 19 22/11/05 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 31 21 YA35 18(1)(c) All new staff must receive structured induction training to Sector Skills Councils Specifications. Requirement first made May 2004 At November 2005 updated LDAF just received - not met. The newly Registered Manager must be provided with formal supervision six times per year as a minimum. Requirement first made at August 05 At November 2005 - one provided dated 17.11.05 Develop an effective quality 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 before October 2003. At November 2005 - part met. 30/11/05 22 YA37 9 31/08/06 23 YA39 24 31/03/06 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 32 24 YA40 13(6) The manager must ensure that 31/01/06 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. Requirement first made May 2004 At November 2005 policy reviewed but not against DOH and BILD standards. The manager must ensure that all risk associated with lone working are identified and managed appropriately. Requirement first made May 2004 At November 2005 have lone working oplicy but no risk assessment with control measures. To provide and maintain window restrictors, based on the assessment of vulnerability of and risk to service users. New Requirement at November 2005. The registered person shall after consultation with the Fire Authority provide appropriate locks on internal doors. New Requirement at November 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 DS0000004806.V256149.R01.S.doc 25 YA42 23(4)(c) 31/12/05 26 YA42 13(4) 31/12/05 27 YA42 13(4) 31/12/05 28 YA43 25(2)(e) 31/12/05 1-3 Adams Street Version 5.0 Page 33 Requirement first made May 2004 Not assessed November 2005.. Ensure accounts and financial plans are available for inspection. (Business plan seen) Requirement first made before October 2003. New Requirement at November 2005 to send accounts and financial plans to CSCI 29 YA43 17(2)/25 31/12/05 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 YA8 YA37 Good Practice Recommendations Involve service users in reviewing the policies and procedures. Manager to obtain qualification identified in National Minimum Standards for Younger Adults. At November 2005 target date to complete is March 2006. 1-3 Adams Street DS0000004806.V256149.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands 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 DS0000004806.V256149.R01.S.doc Version 5.0 Page 35 - 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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