Inspection on 02/04/07 for 1-5 New Street North

This inspection was carried out on 2nd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 38 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-5 New Street North 21/01/08

1-5 New Street North 08/01/07

1-5 New Street North 01/06/06

1-5 New Street North 17/01/06

1-5 New Street North 05/07/05

1-5 New Street North 23/03/05

1-5 New Street North 02/12/04

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 - 5 New Street North West Bromwich West Midlands B71 4AQ Lead Inspector Mrs Cathy Moore Unannounced Inspection 2nd & 3rd April 2007 08:30 1 - 5 New Street North DS0000004798.V330332.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 - 5 New Street North DS0000004798.V330332.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 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 - 5 New Street North Address West Bromwich West Midlands B71 4AQ 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 553 1755 0121 553 4254 Lonsdale Midland vacant post Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th January 2007 Brief Description of the Service: 1-5 New Street is a care home for 8 younger adults who are learning disabled and require additional support due to presenting behaviour that may challenge. The home comprises of 8 single rooms, a domestic style kitchen, 2 bathrooms, laundry, 2 lounges, an activity area, sensory room and a dining area. A lift services the first floor. Entrance to the home is via a coded door lock at the front, leading to the porch area. The home is situated on a slip road just off the main road adjacent to Dartmouth Park in West Bromwich. West Bromwich town centre is within walking distance and parking space is available at the front of the home. There is a lawned area to the front of the building and a small patio area located to the rear. The service has its own transport and regularly accesses local facilities. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels was provided on 5 May 2006 which range between £1,100 - £1,600 per week. These have since changed but although asked for were not provided during the inspection. There are some additional charges for toiletries and hairdressing. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over two days. Two inspectors were on site for the first day between 08.30 and 18.30 hours. On the second day a Commission pharmacist inspector carried out an assessment of the home’s medication systems. We looked at three service user files to include their daily notes, care plans and risk assessments. We looked at three service user bedrooms, the bathrooms, toilets, lounges, dining room, kitchen and laundry. We looked at four staff files to assess the standard of recruitment, supervision and training processes. Two service users and two staff were spoken to during the inspection. The manager and deputy were involved during the inspection process. A pre-inspection questionnaire and service user questionnaires were forwarded to the home prior to the inspection aimed to give the Commission up to date information and the gain the views of service users’ about the service they receive, unfortunately, these were not returned prior to the inspection. The manager confirmed that she had not completed them/ given them out for completion. What the service does well: What has improved since the last inspection? The provider and manager are trying to make improvements however; progress continues to be slow. Two bathrooms have been redecorated and the lounge has been provided with pictures, ornaments and new window dressings since the last inspection to give a more ‘ homely’ feel. Infection control processes in some areas have improved for example; the odour identified during the last inspection has subsided somewhat and cleaning schedules have been implemented. Furniture in the lounge was seen to be of a better standard for example; no torn settee was seen. Two staff meetings and two service user meetings have been held to improve communication within the home. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 6 There has been improvement in terms of reporting incidents occurring between service users’ to the Commission and Social Services. No incidents between service users’ or inappropriate management of service users’ by staff were observed during this inspection. One staff member commented “ Recent changes are a big improvement. You know what you are doing now. J and M are setting us boundaries, things are more structured”. What they could do better: The home continues to fail to meet National Minimum Standards for Younger adults in a number of areas, some of which are of a high risk. The manager and deputy are very keen to improve the home and outcomes for service user’s but are finding it difficult in view of the enormity of the task. On top of this there is conflict within the staff group and a resistance of some staff to comply with instruction and change, which is having a negative impact on the service. A serious concern letter and warning letter were issued following the last inspection. Although the home has started work to address issues they have not all been met in full. The Commission however, acknowledges that many timescales made were 1 May 2007 which gives the home time to further address requirements. After the 1 May a further random inspection will be carried out to fully assess progress made. Care plans, risk assessments and protocols for management of challenging behaviours still need to be produced and implemented to ensure that staff are provided with the correct information to provide care to the service users’ and prevent risk to their health and well being. As with the last inspection evidence demonstrated that more effort is needed to ensure that service users’ are enabled to make choices in terms of the care they receive and for example; when they go out. Improvement is needed to ensure that all service users’ can enjoy stimulating and enjoyable activities. Improvement is needed in terms of staffing. This includes the increasing of staffing levels as previously agreed with the Commission and to allow the correct ratio of staff to service users’ particularly where it has been assessed that individuals needs two staff to escort them out into the community. Evidence showed that there is conflict among the staff team. Some staff are very reluctant to change their practices and follow instruction by seniors and management. We were told that one staff have threatened another and property. Concern was raised in the time delay for one service user who required; ‘as required’ medication for a seizure and the lack of up to date/ individual protocols to give staff instruction on when ‘ as required’ medication should be given. It must be acknowledged that the manager and deputy are trying to implement systems to improve the home. However, most new documentation shown to the inspectors was blank and has yet to be put into operation. 1 - 5 New Street North DS0000004798.V330332.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 - 5 New Street North DS0000004798.V330332.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 - 5 New Street North DS0000004798.V330332.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): 1,2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose must be finalised and be put into operation. In put from required resources need to be secured for each service user to ensure that all their assessed and known needs are being met. EVIDENCE: The manager was able to show us a service user guide that she is in the process of producing which is positive. The document I saw is being produced in both writing and pictures to help service users’ understand it. As the document has not yet been finalised it is not yet in operation within the home or available to service users’ and others. The manager showed us new service user documents, including a set of assessment tools that have been produced to use for future admissions. These have not been used as yet, as no new service users’ have been admitted to the home for some time. The manager has produced a wall chart detailing appointments and referrals to other agencies which is positive however, to date, not all service users’ have been seen by these agencies. Concern was raised with the manager about meeting service users’ safety and health care needs for example; one staff member confirmed that she regularly 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 10 takes one service user (S) out on her own. Previous communication with the home confirmed that (S) requires two staff when going out in the community. It was concerning to be told by the manager that she was not aware that two staff were needed to take (S) out. Further, the staff member spoken to confirmed that she did not know that (S) has a diagnosis of autism. She further confirmed that she has not received any autism training. Staffing levels are not adequate for the number and needs of service users’ which impacts on outcomes for service users’. One service user spoken to confirmed that he does go out as he likes to but at times has to wait. He had planned to go out on the day of the inspection but was in the home from morning to late afternoon. Although he clearly enjoyed speaking to us and being involved in the inspection he was observed to be agitated and was heard saying to the manager ” I’m bored”. 1 - 5 New Street North DS0000004798.V330332.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): 6,7,8,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments including behaviour management plans, do not provide staff with all information they need to satisfactorily meet the needs of service users’. EVIDENCE: The manager showed us new service user documents including a set of assessment tools. We saw that these were blank. The manager told us that “ These new documents to date have only been used for one service user”. This was confirmed by another staff member who said “ The new forms have only been used for one of the eight service users”. We looked at three care plans. One had recently been produced and contained a lot more information, which is positive. However, all others’ remain of a poor standard. One care plan looked at had been produced in March 2006 and had not since been updated. Care plans seen for management behaviour also 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 12 remain insubstantial and of a poor quality. The manager confirmed that apart from the one care plan that had been updated, the other seven had not. From looking at care plans and speaking to the manager it is confirmed that they lack vital information, which potentially places service users’ at risk. Further, there was still no evidence to confirm that service users’ are involved in their care planning processes, which reduces their level of choice about how they wish to live their lives. Risk assessments and processes have not changed since the previous inspection- which includes processes for behaviour management. Risk assessments in place lacked instruction for example; (SD) risk assessment for ‘Injury to self & others’ stated in the control measures only ‘care plan strategies, NVPCT Interventions and diversional therapies’ it did not expand on what interventions or therapies should be used. There was no date on the risk assessment and no planned review date. A ‘risk assessment index’ for another service user ( WS) showed that six areas of risk had not been reviewed since 8/05 and 9/05. This means that staff are not being given up to date information on how to reduce risk to service users’ or manage their behaviours potentially placing them at risk. The manager confirmed that processes for one service user only have been updated. Concern was raised about an activity record for AT which read 26/03/07 Monday “Lounge playing up”. It is unclear in terms of behaviour and behaviour management what “ Playing up” meanssenior staff, were unable to confirm. Further, this statement shows a lack of staff awareness in terms of valuing people and age appropriate descriptions of behaviour. It is positive that two service user meetings have been held of late. Minutes were available dated 18 March 2007 and 1st April 2007 where a range of topics had been discussed including in-house and external activity provision. It was noted however, that only four service users’ attended these meetings leaving the remaining four without any consultation processes. 1 - 5 New Street North DS0000004798.V330332.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): 12,13,15,16,17. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Only limited opportunities for service users’ for service users’ to participate in on-going activities are available. Staff do support service users’ to maintain contact with their family and friends. There continues to be sufficient evidence to demonstrate that menus are designed to consistently offer and give service users’ choices of healthy balanced meals. EVIDENCE: A number of service users;’ attend external educational or day care facilities on varying days of the week. One service user told us; “ I go to college Tuesdays, Wednesdays and Thursdays”. He further told us; “ I’m looking for a job”. The manager confirmed that they were looking into the possibility of him doing some voluntary type work with the estates manager as he enjoys that type of activity. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 14 We looked at activity provision records and saw that they are not being consistently completed and were showing that suitable stimulation and recreation is being provided consistently. For example; one activity record (WS) we looked at read; Monday- no entry made. Tuesday- Morning watched TV, PM- Out for a drive, Eve – Relaxed at home. Wednesday- morning and PM ‘has been in a lethargic mood, Eve watched TV. Thursday- All day relaxed at home. Friday- Am slept around the house, PM out in the community sightseeing, PM resting in lounge. Saturday- Am out in van rest of day TV in room. Another (AT) read; Monday Am and PM “ Lounge playing up”. Eve- in the lounge. Tuesday-Am out for a drive. PM- Sat in lounge. Eve – out for a drive. Wednesday- Am there was nothing recorded. PM and Eve- relaxed at home. Thursday- Am and PM day centre, Eve Home relaxed in lounge. Friday- Sunday records for each day, all day stated “ Relaxed at home”. It was clear from talking to staff that they do strive to take service users’ out into the community as often as they can however, during an interview with a staff member the following comment was made “Aren’t providing enough stimulating activities for service users’ or community based outings”. One service user however; did say; “ I go out shopping to Merry hill and West Bromwich with the staff”. He also said, which was confirmed by the manger; “ I am going on holiday with the college”. Activity records were also poor for ( S). Staff told us that he attended a jacuzzi session on 23 March 2007. However, when we looked at records for this day neither the daily record nor the activity planner confirmed this activity. A service user spoken to confirmed that he had contact with his family he said; “ I see my family and my mate comes to see me”. He also said; “ I have got a girlfriend”. We were pleased to see that a nutritional screening tool has been obtained and has been put into operation within the home. However, when we looked it was found that this tool was not being used correctly for example; a number indicated that no further action was needed yet, there was no evidence to say how this had been decided as the upper boxes on the tool regarding weight and observation had not been completed. We were pleased to see that food intake charts are available in the home however, these are not being consistently completed to give a clear picture of nutritional intake for example; no supper intake records are being made at all. We saw a board on the wall in the dining room displaying some pictures of food, showing that staff are trying to enhance choice methods for service users’ regarding meals. The manager however, confirmed that this process has not been completed. It was disappointing to see that the picture of the chicken 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 15 on the board reflected the main meal for the previous day rather than that day as the menu for that day offered pasta bake or baked potatoes. The menu for the inspection day was confusing as it was highlighted that service users’ were having pasta bake yet, what was cooking were numerous baked potatoes. The manager told us later that only one service user had selected pasta bake all others baked potatoes. It was positive when we looked at food stocks to see that there was plenty of fresh fruit, vegetables and salad in the home however, that these are offered are not reflected on the menus everyday. There was no evidence to confirm that the dietary needs of the service users’ have been assessed. The manager confirmed that although the local PCT had been approached no assessments have been carried out. To hasten this process the Commission have sent leaflets and dietician contacts to the manager to access this resource. One service user told us that he: “ Makes his own drinks and sometimes his breakfast”. He also confirmed that he eats what he wants, and if staff give him something he does not like he throws it away and has something else”. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Further improvement and development is needed to ensure that service users’ receive personal care according to their preferences and needs. Healthcare services are being or are in the process of being accessed concerning health screening . Some further improvements are needed to ensure that all staff are trained and are competent in all areas of management administration and safety. EVIDENCE: As person centred or comprehensive adequate care plans are not available for seven of the eight service users,’ information regarding their choices concerning personal care delivery remains limited for example; preferred rising, retiring times, bath times and choices concerning baths or showers, preferences regarding male or female support workers were not recorded. It was positive to see that service users were appropriately dressed. One service user confirmed that he chooses his own clothes. When we saw him he was wearing tracksuit trousers and a nice top. There has been an issue raised concerning hourly night checks for all service users’ . In that these checks happen even if there is no assessed need. We did not find any evidence to confirm that staff have been given written instruction 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 17 on who should have night checks and why and who does not need night checks therefore this issue remains unresolved. Further another outstanding issue regarding the use of communal wheelchairs / Occupational Therapy assessment for wheelchair usage remains. The manager told us; “ Referrals have been made to Occupational Therapy but as yet they have not been out”. The manager told us that contacts have been made with various healthcare agencies for screening and other input which is positive. However, to date not all service users’ have been seen. The manager further told us that she is having a meeting with the local PCT regarding further input that can be provided/ accessed. It was positive to see that a new form has been produced for staff to record all healthcare input. However, to date not all service users’ had one of these healthcare recording forms on file and tracking what input they have received to date was difficult. We saw that individual service user incontinence pads were stored in the ground floor toilet . These pads are prescribed to the individual and are therefore their property and should be stored as such with their other personal belongings not in a communal area. A staff member was part observed dealing with medications on the first day of the inspection she was seen signing medication records before she had given the medication to the service user. She was also seen to be touching the tablets when transferring them from the packs to medication tots. Neither of which are approved practices. A problem has occurred since the home relinquished its nursing category in that there is no longer a nurse on duty every shift and not all staff have been trained to give rectal Diazepam, giving the potential for delay in service users’ receiving their vital medication to stop seizures as has recently happened. It is positive that the manager has secured and was able to provide evidence that training to administer rectal Diazepam which is due to take place on 11 April 2007 however, dialogue is still needed with the local PCT for them to approve support staff undertaking this invasive body procedure. Confirmation was provided to the CSCI in March 2007 that approval had been given for one specifically named nurse to give a three monthly injection prescribed to one of the service users which is positive. However, this named nurse has recently left the home therefore to ensure safety this authorisation process needs to be repeated. Pharmacy Inspection During the inspection the deputy manager on duty and one service user were spoken with. All of the service users medicine charts were looked at. One service users care plan was looked at regarding medication. Following the inspection the pharmacist supplying medication to the service and also the manager of the service was contacted. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 18 A medicine policy was available dated 1/8/05 which was accessible to staff. It included information on the receipt, administration and disposal of medication, medication errors and self-administration of medication. The policy was not specific and did not reflect how medication was controlled or handled within the service. The deputy manager stated that ‘ policies and procedures were in the process of being reviewed.’ All medication storage was seen. Medication was secure and locked. Medication was neat and tidy and easy to locate. Some creams and ointments were stored next to tablets and liquids instead of separately. There was no lockable container available for the safe storage of medication requiring refrigeration. The supplying pharmacist had also noted this in a visit on 11/1/07. A box of Beechams powders was stored on a shelf dedicated for one of the service users. There was no GP consent available for this administration. The deputy manager said that ‘the GP had agreed the use of the Beechams Powder verbally’. There was no record of this in the care plan. The Deputy Manager disposed of the Beechams Powder during the inspection. The supplying pharmacist was contacted regarding medicine handling at the service. He felt that overall ‘medication had improved’ in the home and ‘was in part due to the introduction of a blister pack system so that the home had better control. They used to run out of medicines frequently before but this doesn’t happen any longer’. He also discussed how the pharmacy provides separate blister packs for those service users attending a local day care centre. The last key inspection report made a requirement regarding staff training in the safe handling of medication. The supplying pharmacist had also noted this issue in a visit on 11/1/07. The deputy manager stated that ‘currently the manager, two deputy managers and qualified nurses administer medication to the service users. No other members of the staff team had received any training’. Following the inspection the manager was contacted. She stated that ‘training had been organised for 8 members of the staff team. They were enrolled on long distance learning ‘Safe Handling of Medication’ course. There would be further ‘in-house’ training from a nurse within the company. The manager and one of the deputy managers were going to undertake training in assessing staff for competency in medication administration during April 2007. Some service users required the administration of medication by a specialised technique. This included the use of rectal diazepam to control seizures in epilepsy and also the administration of an injection every three months. A letter of authorisation from a GP was seen, which gave permission for one of the trained nurses to administer the injection every three months to a named service user. Further training on the use and administration of rectal diazepam was booked for 8 members of the staff team during April 2007. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 19 One service user was having frequent prolonged seizures. The manager confirmed that the seizures were problematic and were sometimes difficult to control. On one occasion on 23rd March 2007 there had not been a trained member of staff available to administer the rectal diazepam and the on call manager was contacted to come and administer it. The current rectal diazepam protocol, which is the same for every service user, is not specific or suited to the service user. The manager explained that she has discussed this with the consultant psychiatrist as she feels that the service user needs to be reassessed regarding the rectal diazepam and how it should be managed.’ The last key inspection report made a requirement regarding the safety of the medicine keys. The deputy manager held the medicine keys at the inspection and also stated that ‘the keys are held by the person in charge at all times’. The last key inspection report made a requirement regarding unclear written instructions on individual medicine charts, and also to ensure medicine records were clear. The current medicine charts and the previous months medicine charts were all seen and were generally up to date for each service user. A highlighter pen had been used to clearly show the times of administration and also match the colour coding of the medicine blister packs provided by the pharmacy. The handwritten medicine charts were clear and contained full directions to administer the medicines. They had all been double checked and signed by two members of the staff team. They were documented with a signature for administration of a medicine or a suitable code recorded if medicine had not been given for any reason. The receipt of medicine was recorded onto the medicine charts and the date of opening on the original container (box or bottle) was recorded. Balances of medicines were available and recorded in a separate folder. This helps to check that medication had been given to service users as prescribed by the GP. There was no disposal record available at the inspection. The deputy manager said that ‘a returns book has been asked for from the chemist’. The preparation of medication at lunchtime was observed. The deputy manager prepared the medicine in the office and took it through to the main building for each service user. The medicine chart was signed immediately on return to the office. The care plan for one service user was seen together with their medicine chart. The deputy manager stated that ‘none of the service users managed their own medicines’ and she explained that the care plans were new and were in the process of being updated. The care plan documented that the service user did not manage their medication. It showed that the service user had been involved in this decision, ‘Do you manage your own medication?’ with a response of ‘no’ recorded. The care plan included information about each medicine including ‘what it is for?’ and ‘when should you take the medication’. A service user spoken to about his medication said ‘I only have a painkiller for 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 20 headaches. I am able to ask someone when I have a headache and they will give me a tablet. I can swallow tablets OK. I have had a headache three times’. The Deputy Manager informed the inspector that the staff team have a good relationship with the GP practices and that medication review is undertaken. During the inspection the deputy manager contacted a GP regarding the timing of the administration of one of the medicines for a service user. The staff team had become concerned that the medicine given at 8.00am was making the service user very tired at lunchtime and was effectively ‘ruining her day’. The GP had agreed to change the time to 8pm but the label on the bottle stated ‘daily’. A signed and dated ‘fax’ was sent from the GP practice, which stated that the medicine was to be given at 8pm. This was placed into the medicine folder for staff to refer to. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place for service users’ and their representatives to access if they feel they have cause. Protection processes are still lacking in that staff have not all received appropriate training. EVIDENCE: We were provided with the homes’ complaints procedure to look at. This procedure has been produced in pictures and writing. A discussion was held about ways in which service users’ understanding of complaints procedures could be made further and it was suggested that the subject of complaints processes could be discussed in service user meetings. We looked at the complaints log no complaints had been recorded. The Commission has not received any complaints about this home. It must be highlighted that the referral processes to the Commission and Social Service Department has improved since the last inspection. We did not identify any incidents of abuse between service users’ that had not been reported which is positive. Concerns still remain concerning the lack of training for all staff, including agency staff in Non-violent physical crisis intervention methods. The Commission regarding this shortfall issued a previous warning letter and serious concern letter to the home. We examined one agency staff member’s file (RM) and were unable to find any evidence to prove that this training had been received. Further, the manager was unable to confirm that all staff have received abuse awareness training although she did say that a number of staff have been nominated for the training. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 22 Financial processes were confusing concerning the withdrawal of money from service users’ individual money tins. The manager told us that when money is taken from the tin a receipt is made of what has been taken out. Then when the purchase/ transaction has taken place then the finance sheet is completed receipt retained then the initial receipt destroyed and thrown away. It was explained that a full written record must be held at all times . That receipts must all be retained and that it would be better and ensure greater accuracy if monies initially withdrawn are recorded on the finance sheet rather than a separate sheet. We saw evidence to confirm that financial procedures are still not being followed properly for example; financial records for AH had only one staff signature. Concerns were raised during the last inspection about service user money being used to purchase items such as bed clothing. This issue was to be discussed with relevant contactors/ commissioners. To date the issue has not been discussed and service user personal money is still being used for bedroom items. For example; we were concerned to see receipts of service user monies used for bedroom items as follows; Receipt dated 02/07/07 6 pile towel set £7.98 Single fitted sheet £2.99 Single bed complete set £6.99. Receipt dated 16/02/07 Hanging shoe organiser £1.99 Hanging sweater organiser £ 1.99. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The standard of the home continues to vary some areas are more comfortable and maintained than others. The home is generally clean and bright. More development is needed in terms of infection control. EVIDENCE: We randomly looked around the home, which included the viewing of three bedrooms, all lounges, the dining room, bathrooms, toilets, kitchen and laundry. Whilst a number of areas were satisfactory some redecorating work is needed concerning décor of landings and bedrooms where wall paper is ripped and paintwork damaged by . It was positive to see that work has been undertaken to enhance some areas of the home and to make it feel more ‘ homely’. The main lounge has a clock and pictures on the walls and new window dressings and two bathrooms have been decorated. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 24 The manager told us positively that plans are in place for the sensory room to be brought downstairs to increase accessibility and usage. She also told us that new television cabinets have been ordered. During our time spent looking around the premises we on a number of occasions heard ‘shrill sounds’ which came from door alarms and the phone. This noise could be upsetting and in fact startling if not expected. Ways should be looked into for reducing these noises. It was extremely positive to find that the strong odour detected on the landing during the last inspection has decreased significantly. Also that the manager was able to provide us with copies of completed cleaning schedules. During our look around the premises we saw a number of infection control issues that need to be addressed examples being; disposable gloves left by the toilet in the ground floor bathroom possibly allowing them to be contaminated. The jug and bar soap in the first floor (male) shower room could be a source of infection transmission. The ventilation system in the ground floor bathroom was covered in a film of dust. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 25 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): 32,33,34,35,36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have still not received all of the required vocational, specialist and mandatory training. Staffing levels still need to be increased to meet the assessed and known needs of the service users’. Conflict and alleged poor attitude within the staff team must be managed and resolved. Recruitment practices need improvement to ensure that they protect the service users’. EVIDENCE: Although it is positive that the manager was able to provide evidence to suggest that staff have been put onto LADAF training not all folders were available for us to see. NVQ attainment still remains low within the home although there are plans for more staff to be enrolled onto this training. Four staff files were sampled none evidenced that they have received all of the required specialist or mandatory training. The manager did tell us however, that a number of staff have been nominated for training in the near future. Staffing levels continue to be inadequate as demonstrated earlier in this report where it could not be confirmed that the correct ration of staff to service user is being provided. That staffing levels have not been increased was evidenced by staff rotas and confirmed by the manager who said; “ Staffing levels are still the same”. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 26 Recruitment processes are still not meeting the standard. We looked at four staff files. Staff files are not organised making auditing difficult. To address this the manager has purchased new file holders. She told us; “ I brought these the other day and am going to re-organise the files”. There was no application form on one staff members file preventing an audit of employment history. There was no photo on file for one staff member, another the photo was so poor the person would not be recognisable. For two staff there was no evidence of CRB’s. For two staff there was no evidence of terms and conditions or a job description. Issues of concern were told to us during the inspection. As these were said to us verbally, the manager not able to provide written records or statements about these incidents ( she confirmed that ;” statements have not been taken from staff involved”), for the purpose of this report we will refer to these issues as accusations. It was highlighted that there is a possible conflict within the staff team among established staff, new staff and management. One staff member got upset and talked about staff “ sabotaging efforts made”. We were told that; “Some staff wanted things to fail so that the home would be closed and that “ A petition was planned to get the manager out”. We were told that a bet of £20 had been made by staff that ;’The newly redecorated bathroom would be taken apart” and that .“ One staff member said; “Done it to the men’s bathroom it was decorated last Thursday and now it’s been sabotaged- rails pulled off”. When asked this person could not however, confirm for sure who had done the damage, weather it was a coincidence and accidental damage by a service user, or weather it was intentional by staff. A further concern was raised of one staff being threatened by another ‘that if she did not join in she would be put on ( threat) the Protection of Vulnerable Adults (POVA) list’. In an attempt to resolve present difficulties the organisation has moved a number of staff to other homes’, replacing them with ‘more experienced staff’, for a month. We raised our concerns with the manager- in that there had been no statements taken about these incidents, no investigation and that if these allegations are as said- staff with very poor attitudes and concerning behaviours are to return to work with service users’ who are extremely vulnerable. We were surprised to hear about these events, as the Commission has not to date received any Regulation 37 regarding staff misconducts, as they should have. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Improvements are needed in a number of areas to ensure management consistency , adequate self assessment of the service to prevent the major shortfalls identified during this and past inspections and to enhance health and safety. EVIDENCE: The manager has been in post since October 2006. She assured us during the inspection that she had forwarded her application for registration to the Commission. Unfortunatley, two days later we checked on the progress of her application and were told by the Commission’s central registration team that an application had not yet been received. The manager ( and deputy) are keen and committed to improve the home to ensure that it meets National Minimum Standards and Regulations. We told the manager that she had an enormous task in front of her, as many requirements 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 28 held a timescale of 1 May 2007. She told us; “ I will get the work done in time”. Which demonstrates her sense of motivation and challenge, which is positive. The manager was able to show us processes that have yet to be implemented for quality assurance / quality monitoring. These included service user questionnaires and a self- assessment tool for the service. These tools have yet to be put into operation. The manager showed us written evidence to confirm that the organisation contracted an external person to undertake a quality audit of the home in autumn 2006. This person gave the home an overall rating of 63 . The issue raised about the lack of annual servicing of wheelchairs at the last inspection still needs to be addressed in full. The manager confirmed that; “One wheelchair is available within the home and a referral has been made for this to be serviced, but it has not been serviced yet”. As with the last inspection concerns were raised about an aerosol can left unattended in the ground floor bathroom. Service users’ have access to this toilet and therefore, there is a potential risk hazard. We looked at the kitchen. The manager told us that this room is to be refurbished soon but as yet there is no firm date for the work to be started. We saw that the ceiling is badly stained and is in need of a good clean. We saw that there were inconsistent recordings of the fridge and freezer temperatures. For example; we saw that fridge and freezer temperatures had not been recorded since 31/03/07. Further when we checked the thermometer in the freezer we found that it was not working. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 29 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 3 3 1 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 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 1 33 1 34 1 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 1 x LIFESTYLES Standard No Score 11 x 12 1 13 2 14 x 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 2 x 1 x 1 x x 1 x 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes 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 6 (a) Requirement Timescale for action 01/05/07 2 YA3 14 3 YA6 14 4 YA6 15 The Statement of Purpose and Service User Guide must be kept under review and must accurately reflect the services provided. (Previous timescale of 30/06/06 not met). The registered person must 01/05/07 demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home, and to further demonstrate it offers care based on current good practice and reflects relevant and clinical guidance (Previous timescale of 30/11/05 is not met). 01/05/07 Service Users’ needs assessments must be kept under review and revised at any time/ as part of a multi agency approach with other professionals. (Previous timescale of 31/10/05 is partly met). 1) To reproduce care plans 01/05/07 DS0000004798.V330332.R01.S.doc Version 5.2 Page 31 1 - 5 New Street North in a format suitable for service users. 2) To introduce effective evaluation, monitoring and reviews of service users’ plans which must be sufficiently detailed to reflect the changing needs of service users, and the objectives set. (This must be carried out at least six monthly). 3) Ensure that the care plans are compiled with the service user and/or their representative, (and significant professionals), and are dated/signed. (Previous timescale of 30/11/05 is not met). To generate a care plan for latest service user admitted from an holistic assessment of need which covers all aspects of personal, and social support and health care needs as set out in the National Minimum Standards 2. (Previous timescale of 1/9/06 is not fully met). To carry out a review and expand all service users’ care plans in order to ensure that all aspects of personal, social support and healthcare needs are fully detailed. To ensure that service users’ are supported to manage their own finances and that care plans contain goals and objectives with regard to the assistance that is needed. Previous timescale of DS0000004798.V330332.R01.S.doc 5 YA7 15 01/05/07 1 - 5 New Street North Version 5.2 Page 32 01/09/07 not met. 6 YA8 12 To demonstrate ways in 01/05/07 which service users are involved in the day to day running of the home and are consulted on issues affecting the service provision. (Previous timescale of 31/10/05 is not met). To expand current 01/05/07 documented risk assessments and risk management strategies with all Service Users, especially relating to their personal safety to be held on their individual plans. (Previous timescale of 1/9/06 is not met). The home must ensure that 01/05/07 the activity plans are reviewed and staff can demonstrate that opportunities for day care and education have been explored. Records of consultation and outcomes should be available and opportunities for service users at the home to take part in valued and fulfilling activities should be in place. (Previous timescale of 30/06/06 is not met). To ensure that all service users are enabled to be politically active if they so wish. (Previous timescale of 1/9/06 is not met). The home must 01/05/07 demonstrate how daily routines and house rules promote independence, individual choice and freedom of movement, and DS0000004798.V330332.R01.S.doc Version 5.2 Page 33 7 YA9 13(4)(c ) 8 YA12 12,15,16 9 YA16 12 1 - 5 New Street North 10 YA17 are subject to restrictions only as agreed in the individual Plan and Contract. Individual working records should clearly set out residents preferred routines, likes/dislikes etc The home must evidence and demonstrate that service users rights are respected and routines are flexible to suit the needs of individual service users. (Previous timescale of 31/10/05 is partly met). 12(1)(a)(16)(2)(i) Nutritional assessments must be undertaken for each service user, kept under regular review and must be acted upon where risk is identified. (Previous timescale of 1/9/06 is not met). To ensure that where service users are identified as having increased dietary needs due to health complications, that either specialist menu plans are established or this is reflected in the existing menu plan, which is closely adhered to, and that staff are more familiar with their dietary requirements. (Previous timescale of 1/9/06 is not met). To ensure that there is more consistent recording of residents’ daily food intake. (Previous timescale of 1/9/06 is not met). To carry out a review of the 01/05/07 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 34 11 YA18 12 current menu plan (obtaining specialist advice from a dietician if necessary), in order to ensure that service users are offered a range of suitably nutritious, varied and balanced dietary options to meet their needs. To ensure care plans contain service users’ preferences with regard personal support including getting up and going to bed and bath times, opposite or same gender care. (Previous timescale of 1/9/06 is not met). To review the practice of hourly checks undertaken during the night for all service users. (If this level of monitoring is deemed necessary it must be discussed and agreed as part of a multi-disciplinary team). Outcomes and guidelines for staff to be documented in individual care plans. To obtain assessments by a suitably qualified professional (for example an O.T.), for three service users who are currently using ‘communal’ wheelchairs. Individual wheelchairs must be obtained if these are deemed necessary. A copy of the assessment must be held in the service user file. Incontinence pads prescribed or purchased for an individual should be DS0000004798.V330332.R01.S.doc 01/05/07 12 YA18 12(1)(a) 12(4)(a) 01/05/07 1 - 5 New Street North Version 5.2 Page 35 13 YA19 12 14 YA20 13(2) stored in their room not communally in toilets. To establish care plans with regard to specific health care health care screening in respect of breast, testicular and cervical cancer screening. (Previous timescale of 1/9/06 is not met). Staff must not sign the medication record until the medication has been given. 01/05/07 01/05/07 15 YA20 13,17 Staff must avoid touching the medications when transferring them from the packs to the medication tots. 01/05/07 The issue of consent to medication needs to be further explored, either with the individual or their representative, or as part of a multi disciplinary review. (Previous timescale of 31/05/06 is not met). To ensure that all staff receive accredited training in the safe handling of medication. Timescale of 01/04/07 not fully met. The registered provider must ensure that the medication policy is reviewed and updated to ensure that it is specific to the needs of the service. The registered provider must ensure that medications for refrigeration are stored safely and securely. DS0000004798.V330332.R01.S.doc 16 YA20 13(2) 01/06/07 17 YA20 13(2) 01/05/07 1 - 5 New Street North Version 5.2 Page 36 18 YA20 13(2) 19 YA20 13(2) 20 YA20 13(2) 21 YA20 13(2) 22 YA23 13,18 The registered provider must ensure that creams and ointments are stored separately from tablets and liquid medications to prevent possible contamination. The registered provider must ensure that any medication given to a service user has been agreed and signed by a medical practitioner to make sure that they are protected from harm. The registered provider must ensure that staff who administer rectal diazepam receive specialist training to make sure that service users’ who require this treatment are protected from harm. The registered provider must ensure that there is a record available for the return of any unwanted medication to the pharmacy. Certificated evidence for all staff that have been provided with training in Adult protection is required to be held on staff files or training provided. (Previous timescale of 31/10/05 is not met). To ensure that there are appropriate systems in place to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse - Urgent Action letter with 28 days of this inspection (6 February 2007). 01/05/07 01/05/07 20/04/07 01/05/07 01/05/07 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 37 To review management behavioural guidelines for all service users to ensure that that are individualised and contain appropriate management strategies (approval and advice must be sought where necessary from other professionals and agreed within a multidisciplinary team). Staff must be fully trained and adhere to management behavioural guidelines at all times. To undertake a documented liaison with Local Authority Commissioning Departments to establish the exact nature of what the basic contract fee covers in terms of service users expenditure. To fully reimburse service users for any items for which they have been inadvertently charged within a timescale agreed by the Local Authority, for example Worn bedding, meals etc. Records must be held on individual service user files. Ensure that all financial records are accurate and retained within the home. To undertake the following improvements to the premises: 1) To repair or replace all broken furniture in communal areas or service users’ individual bedrooms. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 38 23 YA24 12(4)(b) 01/05/07 2)To carry out redecoration of all communal areas or service users’ bedrooms where wallpaper or paint is damaged or worn. 3)consider lowering sounds in the home produced from the door alarms and phone. 4)Door alarms for each service user must be reviewed and only used where an identified need or risk has been identified. To carry out a written audit of all infection control procedures in order to produce and implement an improvement plan in liaison with appropriate professionals (such as incontinence advisor). Disposable gloves available in bathrooms and toilets must be stored appropriately to prevent contamination. The risk of spore and bacteria contamination for items left uncovered in a toilet area was pointed out to the manager. Jugs and bar soap must not be used as communal items but for the individual only and returned to their rooms after use. Ventilation systems in bathrooms and toilets must be checked and cleaned regularly to prevent a build up of dust. Ensure that liquid soap is 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 39 24 YA30 13(3) 01/05/07 25 YA30 13(3) 01/05/07 26 YA31 18(4) 27 YA32 18(1)(c ) provided in the first floor single toilet. To ensure that all staff receive a copy of the code of conduct set by the General Social Care Council with staff signatures maintained to evidence that they have received individual copies. (Previous timescale of 1/9/06 is not met). All staff must receive all specfic training to support their existing skills and knowledge of service users’ individual and specialist needs e.g. epilepsy, autism awareness, disability equality and Makaton. (Previous timescale of 1/9/06 is not met). 01/05/07 01/05/07 28 YA33 18(1)(a) To ensure that all agency staff have received sufficient training in order to meet the needs of the service user group including non-violent physical crisis intervention. Documented evidence to be held on the premises. (Previous timescale of 1/9/06 is not met). The Manager must 01/05/07 undertake an up to date review of staffing ratios and service users dependency levels. To forward written proposals to the Commission for Social Care Inspection. Sufficient staff must be allocated on a daily basis to provide all service users with a range of stimulating activities and opportunities for personal DS0000004798.V330332.R01.S.doc Version 5.2 Page 40 1 - 5 New Street North development as well as meeting care needs. This to include evidence of 1:1 and 1:2 staffing levels as required and agreed to previously. To ensure that the manager’s hours are recorded on the duty rota. Timescale of 01/04/07 not met. Staff conflict and alleged poor attitude of staff must be managed and resolved. Written records of any accusations/ concerning incidents overheard/ witnessed must be made. Records concerning misconducts/ investigations into alleged poor attitude etc of staff must be recorded and be made available for inspection. 29 YA33 17(2) Schedule 6 (f) 01/05/07 30 YA34 19(1) A Regulation 37 must be provided to the Commission concerning any allegations of/ or incidents of staff misconduct. To improve recruitment and 01/05/07 selection procedures in order to safeguard service users from abuse and address issues identified within the inspection report National Minimum Standard 34 and in compliance with the Care Homes Regulations 2001. Schedules 2 and 4. (Previous timescale of 1/8/06 is not met). To cease the employment 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 41 31 YA35 17,18,19 of any agency staff without written evidence to demonstrate checks that they have received appropriate training. Timescale of 01/04/07 not met. To ensure that induction (within 6 weeks of commencement) and foundation training (within 6 months of commencement) is delivered, and is in accordance with guidance issued by the `Skills for Care` Organisation (NTO) To ensure that relevant staff are registered on a `Learning Disability Award Framework` accredited training course. (Previous timescale of 31/10/05 nearly met). To carry out a training needs assessment for the staff team and establish a written central training plan. To continue to progress plans to ensure that all staff received structured and documented supervision (a minimum of six times per year). (Previous timescale of 1/9/06 is not met). 01/05/07 32 YA36 18(2) 01/05/07 33 YA37 8,9 To introduce an annual appraisal system for all staff. To establish and forward an 01/05/07 individual personal plan for the manager of New Street to CSCI by the date given (which includes training such as the Registered DS0000004798.V330332.R01.S.doc Version 5.2 Page 42 1 - 5 New Street North Manager’s award). To ensure that an application for Registration of the manager is forwarded to CSCI for processing by 19 February 2007. Timescale of 01/04/07 not met. Central registration team in Birmingham on 03/04/07 confirmed that to date no application has been received. The Acting Manager must 01/05/07 produce an Annual Development plan, which is based on a systematic cycle of planning-action-review and reflects the aims and outcome for service users (Previous timescale of 31/3/06 is not met). The service must adopt and evidence an effective system for Quality Assurance based on the outcomes for service users, in which standards and indicators to be achieved are clearly defined and monitored on a continuous basis. The home must explore ways in which the service users, staff and stakeholders can be included in the homes chosen quality assurance system. (Previous timescale of 30/6/06 is not yet met). To provide all staff with manadatory training in: 1) Infection control. 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 43 34 YA39 24 35 YA42 18(1)(c) 01/05/07 2) Food Hygiene awareness. 3) Moving and handling 36 YA42 13(4)(c) 4) First Aid awareness. To improve accident 01/05/07 reporting systems by ensuring that all accidents are more accurately detailed and to introduce a system for monitoring and analysis by the Acting Manager in order to identify potential adult protection, patterns and trends of accidents. (Previous timescales of 1/8/06 and 01/04/07 not fully met). 01/05/07 To undertake the following improvements to promote health, safety and welfare of service users: 1) To ensure that all substances hazardous to health (COSHH) are held securely at all times. 2)To ensure that there is more consistent checking of fridge temperatures and that staff are aware of what action to take if safe temperatures are exceeded or not reached. 3)To ensure reporting systems are implemented to make management aware when fridge thermometers are not working. 4)To ensure that foodstuffs such as sacks of potatoes 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 44 37 YA42 13(4)(c) are not stored directly on the floor. 5)To ensure that all short life products such as sauces are date labelled when opened and discarded after six weeks of opening or as per manufacturers guidance. 6) To ensure that the kitchen ceiling is thoroughly cleaned. 7)To ensure that all wheelchairs receive an annual inspection and service. 8) To introduce regular health and safety checks for all moving equipment such as wheelchairs and bath hoist with records maintained. Staff must follow 01/05/07 instruction concerning (WS) wardrobe and not store clothes on the top shelf. 38 YA42 13(4)(C ) 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 YA1 YA2 Good Practice Recommendations To develop a service user guide in a format suitable for service users. To develop an assessment tool which covers all topics in DS0000004798.V330332.R01.S.doc Version 5.2 Page 45 1 - 5 New Street North 3 4 YA6 YA17 National Minimum Standard (NMS) 2.3 to assist in assessment of potential service users, and periodic reassessment of existing service users’ needs. The home should continue with its plans to implement a system of person centred planning or similar, such as Essential Lifestyle Planning or Life Story books. Menus could be made available in different formats with pictorial options produced using photographs to assist service users to make a choice. To provide staff with guidance regarding exploring different strategies for enabling residents to make choices from the daily menu and in menu planning, for example using objects of reference, taster sessions. To consider introducing a more comprehensive nutritional screening tool such as the ‘ Malnutrition Universal Screening tool’ ( MUST) in order to identify issues relating to malnutrition and obesity and which utilises a body mass index scoring system. To ensure that there are two staff signatures for all transactions. To provide a range of sensory and tactile equipment for service users’ bedrooms. The home should continue to work toward meeting Sector Skills Workforce targets of 50 of care staff having achieved an NVQ level 2 or above. To consider purchasing a larger or second fridge/freezer. To introduce a system for regular calibration of the food probe with written records maintained. 5 6 7 8 YA23 YA29 YA32 YA42 1 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 46 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 - 5 New Street North DS0000004798.V330332.R01.S.doc Version 5.2 Page 47 - 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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