Inspection on 05/02/07 for 1-3 Adams Street

This inspection was carried out on 5th February 2007.

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 no outstanding requirements from the previous inspection report, but made 22 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 22/11/05

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 Lesley Webb Key Unannounced Inspection 5th February 2007 09:30 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 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 *** Post Vacant *** Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2006 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 DS0000004806.V326518.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector with the home being given no prior notice. During the visit time was spent talking to service users and staff, examining records and observing care practices before giving feedback about the inspection to the Acting Manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case-tracking care provided at the home. No relatives of residents were present during the inspection. Fees charged for living at the home range between £566.98 and £817.87 per week. What the service does well: Individuals are involved in decisions about their lives. The Acting Manager has introduced ‘Talk time’ where service users have one to one discussions in order that their views and opinions can be sought and acted upon. In addition to this records confirm that service users are offered the opportunity to participate in staff meetings as well as service user meetings. Generally people who use this service are supported to make choices about their life style, and supported to develop their life skills. As one service user explained, “I go with staff to do the shopping because you have to be careful carrying lots of money, but go to bingo by myself, I don’t need any help with this”. There are no set times for meals within this home. One service user stated, “I have my dinner when I want, it depends what I have got planned for the day”. The inspector sat and observed practices during the early evening when a meal was being prepared. The atmosphere was very relaxed, with lots of laughter. People who use this service are able to express their concerns. Since the Acting Manager has been in post service user meetings have been introduced, with the minutes of these evidencing that this forum is used to allow service users to raise concerns or complaints. In addition to this ‘Talk time’ sessions have been introduced, again as a venue for service users to raise issues. Generally the environment is safe and comfortable and encourages independence for the people living there. This was confirmed by one service user who said, “what do you think of the decorating, we did this last year, its nice don’t you think”. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager has insufficient supernumerary hours to effectively manage the home. Evidence from previous inspections and also generated from this inspection indicates that this is having a negative impact on the management and running of the home and action must be taken to address this. The Acting Manager appears dedicated to improving what was previously a poorly managed service but without sufficient supernumerary management hours improvement cannot be achieved and maintained. Further work must be undertaken to ensure care planning and risk management is completed and updated on a regular basis, based on each person’s individual needs and capabilities. It is acknowledged that the Acting Manager has only been in post for a few months but priority must now be given to reviewing care plans in order that the home is confident all service user needs are being met and managed appropriately. Staff require further training in order to maintain their knowledge. This must include autism, epilepsy, communication, disability awareness, equal opportunities and challenging behaviours. The introduction of formal quality assurance systems will allow the home to measure if it meeting its aims and objectives. A previous requirement to introduce a quality assurance system remains in place. The Acting Manager states that the company is planning to introduce a formal system later in the year and that documentation is now in place ready for this. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available to prospective people considering if this home will meet their needs, however in some instances this is not up to date and is misleading. EVIDENCE: The home has a statement of purpose and service user guide, with some evidence that service users have been made aware of the contents of these documents. A previous requirement to ensure the statement of purpose includes staff qualifications remains unmet. The Acting Manager informed the inspector that he was aware of the need for this information to be included in this document and that it was his intention to do this once training has been completed. When discussing information required by regulation the inspector advised the Acting Manager to obtain the updated version of the Care Home Regulations 2001 and alter any documentation within the home to reflect the amendments in this legislation. It is also recommended that the home obtain a copy of ‘Inspecting for Better Lives’ (a document produced by the Commission for Social Care Inspection - CSCI) as an information tool that can be used within the home. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 10 There have been no new admissions to the home since before the last inspection. However a requirement identified in the previous inspection to review the admissions policy to ensure its accuracy of the admissions criteria was assessed. The policy still states the home would admit someone with a physical disability despite it not being registered for this category. The Acting Manager spoke by telephone to the Operations Manager who stated that if the company were to receive a referral for someone with a physical disability the organisation would look to see if the environment could be adapted and then make an application to CSCI to vary its registration category. The inspector informed the Acting Manager that this process and information must be included in the admissions policy, with detail given to explaining that until a variation is accepted someone with a physical disability would not be allowed to live at the home. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives. Further work must be undertaken to ensure care planning and risk management is completed and updated on a regular basis, based on each person’s individual needs and capabilities. EVIDENCE: The Acting Manager has been in post since 1st December 2006. At the time of this inspection he confirmed that no work has yet been undertaken to ensure care plans, associated documents and risk assessments are in place for all identified needs or that these are regularly reviewed. He produced documentation that has been introduced including activity records, daily records and some health records explaining that it is his intention that all records relating to service users will be reviewed, amended and a new system for care planning introduced. He explained that he had introduced daily records first in order to assess staffs knowledge and that he wanted to wait 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 12 until the home had been inspected before reviewing the care planning that has previously been in place. Upon inspection of the care plans that currently are in place at the home the inspector found that these do not cover all identified needs, in some instances lack clear guidance for staff and have not been reviewed for several years. It is acknowledged that the Acting Manager has only been in post for a few months but priority must now be given to reviewing care plans in order that the home is confident all service user needs are being met and managed appropriately. Observations made during the inspection indicate that person centred approaches to care are in place. For example service users were assisted to undertake tasks based on their individual needs and choices, individuals views were sought before offering assistance and routines of the day were individualised. A member of staff was witnessed bringing mail to a service user, who then opened it and asked staff for assistance to read contents, with the service user confirming this is normal practice. It is recommended that documentation be implemented that supports these practices and that staff receive training to compliment this form of care planning. Discussions with service users, observations of care practices and examination of records confirm that service users are supported in decision-making processes. The Acting Manager has introduced ‘Talk time’ where service users have one to one discussions in order that their views and opinions can be sought and acted upon. In addition to this records confirm that service users are offered the opportunity to participate in staff meetings as well as service user meetings. It is recommended that a timetable for all meetings both individual and group be implemented in order that everyone in the home has the opportunity to participate on a regular basis. It is also recommended that the minutes of all meetings include agreed actions and timescales in order that effective monitoring can take place. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people who use this service are supported to make choices about their life style, and supported to develop their life skills. Further work is required to ensure care planning supports individuals social, educational and recreational expectations. EVIDENCE: The three people who live at this home have varying levels of needs and dependency. The Acting Manager has started to introduce documentation in order that these needs can be monitored and appropriately managed. For example social and community diaries have been introduced where all activities are recorded and activity plans are now being completed on a weekly basis. It was pleasing to find evidence that staff discuss the contents of the activity plans with individuals in order to obtain their preferences. Upon inspection of the new documentation the inspector found that these details both in-house and external activities including attendance at various day 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 14 placements, leisure pursuits, education and life skills. It is recommended that when the contents of activity timetables are not adhered to, the reason be recorded. It was also noted that for one service user with limited communication their activity planner states ‘service user choice’. When discussing this the inspector recommended that this be expanded to give specific choices that staff should offer, with the activity that is chosen by the service user then highlighted. By doing this the home should be confident that this particular service user is offered a range of activities and it will also ensure staff who do not normally work with this person are aware of his particular preferences. During the inspection service users were observed discussing at planned holiday to Spain with one stating, “eleven weeks till Spain, I can’t wait” and a service user also informed the inspector that he helps with the shopping stating, “cant go to do this by myself in case I get mugged, you have to be so careful”. Two of the three people who live at this home are supported to maintain contact with family as per their preferences. For example one person attends a church weekly with their family (with records in place) and another has regular contact by telephone. As mentioned earlier in this report care plans needs to be implemented for all identified needs, including social and family contact. Pre-inspection documentation supplied to CSCI prior to the inspection states that there are no set times for meals within this home, that this take place at the request of service users. Discussions with service users and observation of practices confirm this statement to be true. For example one service user stated, “I have my dinner when I want, it depends what I have got planned for the day”. The inspector sat and observed practices during the early evening when a meal was being prepared. The atmosphere was very relaxed, with lots of laughter. One service user was observed being assisted to participate in the preparation of the meal whilst the two remaining service users sat in the dining room playing a game of Roulette with a member of staff. The service users explained that they all take in turns to choose the main meal for the following day but that people can still change their mind. When examining the records of meals taken the inspector found that very little rice, fish and pasta appear to be eaten, with staff confirming service users are “set in their ways” with regards to meal options. It is recommended that the home seek professional advice regarding diet, nutrition and balanced diets to ensure this situation is appropriately managed. Previous requirements relating to nutrition and diet are now met. The Acting manager confirmed that medical advice has been sought in relation to nutrition of one service user and that the provision of fresh vegetables has now increased. As with other aspects of care management the Acting Manager was reminded that care plans and risk assessments must be introduced and regularly reviewed for nutrition and diet. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The principles of respect, dignity and privacy are put into practice. Further work is required to ensure care planning ensures the health and personal care that people receive is based on their individual needs. EVIDENCE: Discussions with service users and staff, and observations during the inspection confirm that the principles of respect, dignity and privacy are put into practice. For example a service user was observed spending time in his bedroom (his choice), with staff knocking on his bedroom door and waiting for a response before entering and staff were heard asking service users their wishes in relation to assistance required. One service user confirmed this as normal practice stating, “staff are great, they let me do what I want, tell me about the danger, like carrying lots of money or I might get mugged, but they don’t stop me doing what I want”. As with all other aspects of care evidence was found that the Acting Manager is introducing systems to ensure the needs of service users are appropriately 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 16 managed, but that further work is still required. Health appointment monitoring and outcome records have been introduced that contain detailed records of appointments but care plans now need to be reviewed and implemented where needed to ensure all health needs are appropriately identified, managed and monitored. The examination of one person’s health records found that staff have recorded non-health related appointments on the same record. It is recommended that this practice ceases and that staff receive guidance in this area. A previous requirement to ensure all service users have access to regular health care checks for example at well person’s clinics remains unmet. The Acting Manager confirmed that all service users have recently changed doctors, and that the new doctor will be sending appointments for everyone in relation to this. It is strongly recommended that the home register all service users and implement the Sandwell Priority Health Screening Tool in order that effective monitoring of all health needs can take place with appropriate intervention by relevant professionals. Since the last inspection the Acting Manager has changed pharmacy supplier, with the home now using the Boots Medication Dispensing System. Examination of medication and records found this to appear appropriate. It was however noted that no service users living at the home self medicate, with no assessments undertaken to support this decision despite the medication policy stating ‘every service user has the right to manage and administer their own medication’ and ‘the home will provide necessary support, advice and aids to self medicate’. As two of the service users residing at the home appear to have abilities that could be encouraged the home must be able to evidence that action has been taken in this area. The Acting Manager informed the inspector that medication training has been booked for March 2007 for staff with the supplying pharmacist. At the time of inspection competency assessments for staff have not been completed, with the Acting Manager confirming these will be introduced when staff have completed training. He also informed the inspector that a new medication cabinet is going to be purchased. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, and have access to an effective complaints procedure and are protected from abuse. EVIDENCE: Service users confirmed they feel happy to raise concerns and all indicated that they would approach either staff or the Acting Manager if unhappy. Since the Acting Manager has been in post service user meetings have been introduced, with the minutes of these evidencing that this forum is used to allow service users to raise concerns or complaints. In addition to this ‘Talk time’ sessions have been introduced, again as a venue for service users to raise issues. As mentioned earlier in this report it is recommended that a timetable for meetings be introduced in order that these venues become a regular event. The home has a complaints policy that appears appropriate. This is also available in an alternative format. Adult protection policies and procedures are in place including a copy of the local authority adult protection guidelines. In addition to these policies and procedures are in place for physical intervention and restraint. Upon examination of these some appear to require reviewing as are dated 2003 and do not evidence changes to legislation since that date. Despite some staff requiring training in physical intervention practices observed during the inspection indicate that some staff appear to have appropriate knowledge in this area. A service user was seen to become distressed and agitated. Staff 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 18 on duty offered assistance, talking quietly and calmly with this reassuring the service user. None of the three service users residing at the home manage their own finances. Records viewed demonstrate that individual personal allowances sheets are maintained for each person along with receipts for purchases. Records indicate that service users are assisted to withdraw money from their bank account, which is then taken to the head office of the company to pay for part of their fees for living at the home. The inspector questioned why some of this was then returned every time to the service user. The Acting Manager was unable to answer this, agreeing that this should be investigated and clarified. All monies checked were correct and corresponded with amounts detailed on personal allowances sheets. As mentioned in other parts of this report action must now be taken to ensure care plans and risk assessments are in place that are up to date and support the financial needs of service users. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the environment is safe and comfortable and encourages independence for the people living there. Further improvements to infection control practices will ensure safety is not compromised. EVIDENCE: The home is three bedded, domestic in nature and appears appropriate for the people residing in it. Pre-inspection documentation supplied to CSCI states that the lounge has been decorated since the last inspection, with this confirmed by a service user who stated, “what do you think of the decorating, we did this last year, its nice don’t you think”. A previous requirement to review the practice of locking an internal door is now met, with the Acting Manager confirming this no longer occurs. A tour of the building was undertaken, including two service users inviting the inspector to look at their bedrooms with only minor works required. The home has two lounge areas one of which is a designated smoking area for a service user. The inspector 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 20 instructed that the home seek advice from the Environmental Health Department with regards to the current situation and the legislation that is due to take effect from July 2007 as the current situation in the home has the potential to compromise the wishes and wellbeing of none smokers. For example there is no extraction system and doors are open at all times. As the inspector explained the home has a responsibility to manage one service users rights but also to ensure they do not impact on the health and well being of others living at the home. The external grounds of the home appear adequately maintained (a handrail was loose but repaired immediately upon instruction). The home must seek advice regarding access to and around the home to ensure efforts are made that it complies with the Disability Discrimination Act, as currently there is a steep step that is not easily identifiable and there appears to be little consideration made in relation to access to the building (apart from a hand raid). A previous requirement to take steps to improve infection control practices within the home ensuring staff know how to reduce the risk of cross contamination is part met. The Acting Manager informed the inspector that he asks questions of staff within supervision and monitors practices. He also stated that all staff are booked on infection control training for March 2007. Until evidence of this occurring is in place this requirement still stands. With regards to infection control personal protective equipment was found to be sited in various locations and staff and service users were observed using this equipment. Infection control measure in relation to the storing and sanitizing of mops need further improvement. Colour coded mops and buckets are in place for various areas of the home but appropriate storage and cleaning schedules are required to ensure cross contamination does not occur. The home has an area with a washing machine and dryer that is accessible through the kitchen. Staff informed the inspector that advise had been sought from the Environmental Health Department regarding this with the home instructed this was acceptable as long as soiled laundry was transported in sealed containers. It is recommended that written clarification be sought to verify this. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff appear to have the appropriate skills and are in sufficient numbers to support the people who live at the home. The manager has insufficient supernumerary hours to effectively manage the home and staff require further training in order to maintain their knowledge. EVIDENCE: The Acting Manager produced evidence that arrangements have been made for staff to receive training in various areas, however greater efforts must be made to ensure specialist training to meet the needs of people living at the home is undertaken. This must include autism, epilepsy, communication, disability awareness, equal opportunities and challenging behaviours. Observations made throughout the inspection indicate that staff have attitudes and characteristics suitable for working and supporting people living at the home. Interactions between staff and service users were very relaxed, friendly and informal. The atmosphere was welcoming and happy. Records confirm that two staff hold a national vocational qualification. This is not sufficient and arrangements must be made for all staff to enrol on this qualification. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 22 Staff rotas were examined and found to detail that two staff are on duty during the day and early evening, with a waking person on duty during the night. The inspector was concerned that only five hours are allocated to the Acting Manager to undertake management responsibilities and that his remaining hours are included as care. Evidence from previous inspections and also generated from this inspection indicates that this is having a negative impact on the management and running of the home and action must be taken to address this. The Acting Manager appears dedicated to improving what was previously a poorly managed service but without sufficient supernumerary management hours improvement cannot be achieved and maintained. The inspector instructed that any care and management hours must be clearly identifiable on the rota for monitoring purposes. Due to previous issues relating to poor recruitment practices the employment records of all staff working at the home were examined. These found that in general the required records as detailed in the Care Home Regulations 2001 are in place, apart from no staff files containing a copy of their contract of employment, two not containing the required amount of identification and one missing a copy of their job description. Of concern however, is that no employment records for bank staff whose permanent place of employment are other establishments owned by the company could be viewed. The home currently has several care vacancies, with the Acting Manager explaining that interviews are currently being undertaken to fill these positions. The home does not use agency staff but has been using four staff who work at other homes owned by the company to fill these. The Acting Manager contacted head office and was informed that keys were not available to access records but that records could be brought to the home the next day. The inspector explained to the Acting Manager that records must be accessible at all times, to which manager agreed. The home has a recruitment policy that appears to contain basic information. It is recommended that this be reviewed to ensure it complies with legislations, as it has not been reviewed since 2005. As mentioned earlier the Acting Manager produced evidence that training has been arranged for staff. Systems now need to be introduced to ensure training is systemically managed. This should include the introduction of a training and development plan and individual training and development assessments for all individuals. The Acting Manager has introduced formal supervision for staff since taking up position in December 2006. He confirmed that staff appraisals have yet to be introduced. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Acting Manager appears to run the home based on openness and respect. The introduction of formal quality assurance systems will allow the home to measure if it meeting its aims and objectives. EVIDENCE: The Acting Manager has been in position since the 1st December 2006. His experiences and qualifications include previous management of a learning disability service, holding a national vocation qualification level four in care and the registered managers award, in addition to undertaking short courses. As the Acting Manager explained, “anything that will give me the knowledge that I can pass on to the staff I will do the course”. The Acting Manager confirmed that once he has completed his probationary period he will be making an 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 24 application for registration. Service users and staff all praised the new manager, confirming that he is approachable and offers support. A previous requirement to introduce a quality assurance system remains in place. The Acting Manager states that the company is planning to introduce a formal system later in the year and that documentation is now in place ready for this. The views of service users have been obtained through satisfaction questionnaires, with action taken to address any issues raised. The Acting Manager also stated that he had spoken to the day centres that service users attend to obtain their views of the home, with every stating they are happy with the home, however no records were available to validate this comment. The inspector reinforced that as part of the quality assurance system the views of everyone including service users, their representatives and other interested parties must be obtained, analysed and the findings incorporated into the annual development plan that needs to be introduced. As mentioned in various sections of this report further improvements to records are required. The Acting Manager demonstrated understanding in this area, but as mentioned earlier the inspector questions if this will be possible with only five management hours allocated to the running of the home. Action must be taken to address this if the home intends to improve the quality of service provided. Generally health and safety appear appropriately managed at the home. Information supplied to CSCI prior to the inspection states that fire equipment was checked August 2006, fire alarms are tested weekly, a Legionella check undertaken November 2006, a gas safety certificate issued August 2006 and an electrical wiring certificate issued November 2005. The home should be congratulated for involving service users to understand safety. On arrival at the home the inspector was introduced to a service user who then escorted the inspector around the building, showing fire exists, COSHH cupboard and kitchen area. As mentioned in section 24 of this report some improvements to the arrangements for service users who smoke must be made. It was also noted that comments were made that staff currently smoke in the dining room. This is totally unacceptable and must stop, with clear policies and procedures put into place. Control of substances hazardous to health are appropriately stored and managed, however it is recommended that data sheets and risk assessments are located in the same area as where products are stored for ease of reference. It is also recommended that an audit of the data sheets be undertaken and those in place for items no longer used be removed. A first aid box is located in the kitchen area containing all required items (clear plasters were removed immediately upon request of the inspector). It is recommended that a second first aid box be purchased and located on the first floor of the building for ease of use in an emergency. In relation to fire drills the inspector was pleased to find evidence that the Acting Manager has introduced comprehensive records that demonstrate both staff and service user involvement, response times and assessments of outcomes (with the last 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 25 drill occurring 15th January 2007). The numbers of staff holding up to date certificates for first aid, food hygiene and fire are adequate, but further work must be undertaken to ensure sufficient numbers of staff have undertaken health and safety and moving and handling. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 3 2 X 2 2 X 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 27 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4,5,6 Requirement The Registered Provider must review the Statement of Purpose ensuring staff qualifications are included – not met. Requirement originally made July 2006. The statement of purpose, service user guide and contracts of residency must reflect amendments to the Care Home Regulations 2001. Review the admission policy for the home ensuring the accuracy of the admissions criteria – part met. Requirement first made October 2003. The admissions policy must include clear and detailed information informing people that they will not be able to live at the home if they have a physical disability unless the home applies for a variation of registration and that this is approved by CSCI. 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 28 Timescale for action 31/05/07 2 YA2 16(1) 23(1) 31/05/07 3 YA6 15 Care plans must be introduced for all identified needs including personal, health, social, emotional and financial needs. These must be based on each person’s needs and capabilities and be regularly reviewed. Care plans must include specific aims and goals. The home must be able to evidence that service users are actively involved in the compilation and reviewing of care plans. That risk assessments are completed for all identified needs. That risk assessments are regularly reviewed. Ensure service users have access to regular health care checks e.g. well person clinics – part met. Requirement first made October 2003. That self-medication assessments are completed for all service users based on their individual needs and capabilities, as per the homes medication policy. That medication competency assessments are completed for all staff. That these are reviewed on a regular basis. That the home purchases a medication cabinet that complies with the Misuse of Drugs Act 1989. That the home reviews its protection and physical intervention policies and ensure they comply with relevant legislation. DS0000004806.V326518.R01.S.doc 31/03/07 4 YA9 13(4) 31/03/07 5 YA19 12(1) 13(1) 31/03/07 6 YA20 13(2) 31/05/07 7 YA20 13(2) 31/05/07 8 YA20 13(2) 31/05/07 9 YA23 13(6) 31/05/07 1-3 Adams Street Version 5.2 Page 29 10 11 YA24 YA24 16(2)(c) 16(2)(j) That all staff undertake physical intervention and challenging behaviour training, with certificates maintained. That any worn or torn bedding is replaced. That advice be sought from the Environmental Health Department with regards to the current situation for smoking in the home and legislation that will take effect from July 2007. That advice be sought and action taken to ensure efforts are made that the home and grounds comply with the Disability Discrimination Act. That all staff undertake infection control training. That systems be introduced for the appropriate storage of mops and buckets. That a written policy and procedure be introduced for the sanitizing of mop heads. All staff must undertake autism, epilepsy and communication training, with certificates maintained. All staff must either hold a national vocational qualification or be enrolled to undertake this qualification. A minimum of 24 hours per week must be allocated to the manager, supernumerary to care for management responsibilities and duties. 31/03/07 31/05/07 12 YA30 16(2)(j) 31/03/07 13 YA32 18(1)(a) 31/05/07 14 YA33 10(1) 18(1)(a) 28/02/07 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 30 15 YA34 19 The staff rota must clearly detail any care hours undertaken by the manager and those undertaken in his capacity as manager. 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 – part met. Requirement first made January 2005. All employment records as identified in Schedule 2 and 4 of the Care Homes Regulations 2001 must be in place prior to the commencement of employment of any staff with records maintain and open for inspection at all times – part met. Requirement first made October 2003 That a training and development plan be introduced at the home. That individual training and development assessments are introduced for all staff. That all staff undertake equal opportunities and disability awareness training. The Registered Provider must ensure that annual staff appraisals are carried out for each staff member and the Manager – not met. Requirement originally made July 2006. DS0000004806.V326518.R01.S.doc 28/02/07 16 YA35 18(1) 31/05/07 17 YA36 18(2)(a) 31/05/07 1-3 Adams Street Version 5.2 Page 31 18 19 YA37 YA39 8 24 That an application to register the Acting Manager is made. 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 Commission for Social Care Inspection. Action must be progressed within timescales to implement requirements from National Care Standards Commission inspection reports – not met. Requirements first made before October 2003. That records required by regulation are in place and up to date. That the practice of staff smoking in the dining room ceases immediately. That the home introduces written policies and procedures for smoking. That these comply with legislation that takes effect July 2007. That all staff undertake health and safety and moving and handling training. 31/05/07 31/05/07 20 21 YA41 YA42 17 13(4) 31/05/07 31/05/07 22 YA42 13(3)(5)(6) 31/05/07 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 Page 32 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations That the home obtains an up to date copy of the Care Home Regulations 2001. That the home obtains a copy of ‘Inspecting for Better Lives’. That person centred plans be introduced. That staff receive training in person centred planning. That a timetable for ‘talk time’ and service user meetings be implemented. That the minutes of meetings include agreed actions and timescales. That the home continues with the implementation of activity timetables. That when the contents of activity timetables are not adhered to, the reason is recorded. That a choice of activities is recorded on the activity timetable for the service user with specific communication needs. That advice is sought from a relevant professional with regards to ensuring service users receive nutritionally balanced diets. That the home ceases the practice of recording non-health related appointments on health documentation. That the home registers all service users and implements the Sandwell Priority Health Screening Tool. That the home obtain information relating to the maximum amount of money that the home is insured to hold. That written evidence be sought from the Environmental Health Department with regards to the transportation of soiled laundry through the kitchen. That the homes recruitment policy be expanded to contain comprehensive information and guidance. That computer and internet access is available in the home. That COSHH data sheets and risk assessments be located DS0000004806.V326518.R01.S.doc Version 5.2 Page 33 2 3 YA6 YA7 4 YA14 5 6 7 8 9 10 11 12 YA17 YA19 YA19 YA23 YA30 YA34 YA37 YA42 1-3 Adams Street in the same area where products are stored. That an audit of data sheets and risk assessments be undertaken with information that is no longer applicable removed. That a second first aid box be purchased and located on the first floor of the building. 13 YA42 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1-3 Adams Street DS0000004806.V326518.R01.S.doc Version 5.2 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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