Inspection on 24/10/06 for 1 Great Wood Road

This inspection was carried out on 24th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Great Wood Road 25/06/07

1 Great Wood Road 25/05/06

1 Great Wood Road 09/03/06

1 Great Wood Road 24/10/05

1 Great Wood Road 07/03/05

1 Great Wood Road 19/08/04

1 Great Wood Road 09/03/04

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 Great Wood Road, 1 Small Heath Birmingham West Midlands B10 9QE Lead Inspector Brenda O’Neill Unannounced Inspection 24th October 2006 09:00 Great Wood Road, 1 DS0000016922.V315722.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 Great Wood Road, 1 DS0000016922.V315722.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. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Wood Road, 1 Address Small Heath Birmingham West Midlands B10 9QE 0121 773 0017 0121 773 0247 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) FCH Housing & Care Miss Samantha Slater Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 25th May 2006 Brief Description of the Service: 1 Great Wood Road is a two storey home offering ground floor accommodation to service users, with the top floor being used for office space. The home caters for 4 service users with learning disabilities and diverse needs, some experiencing mobility difficulties. All service users have their own individualised bedroom. There is a car park to both the front and rear of the property. To the front is a small garden and planted area equipped with seating, that residents could use in the better weather. The fees at the home are stated in the service user guide as being £326.44 per week for the standard cost of a placement. Fees are negotiated on an individual basis dependent on the service users’ needs. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection for 2006/2007 at the home. It was carried out by two inspectors over one day in October 2006. During the course of the inspection two service users’ files and some staff files were sampled as well as other care and health and safety documentation. The inspectors met with all of the service users, spoke to one relative, the manager, the service manager and two staff members. At the previous inspection in May 2006 numerous requirements were made of the home. Much of the time at this visit was spent assessing the progress made towards meeting the key standards of the National Minimum Standards. The home had had no complaints made to them since the last inspection and none had been lodged with the CSCI. What the service does well: Adequate staffing levels were being maintained to meet the needs of the service users. Service users were comfortable in the company of staff and good relationships were evident. Staff knew the needs of the service users and were able to communicate with them in ways preferred by the service users. Service users in this home had complex needs and were reliant upon staff to interpret their non-verbal communication to ensure their needs and wishes were met. During the inspection staff were observed to be working along these lines with service users and encouraging them to make choices. Service users were provided with a good variety of food with choices available to them. Cultural diets were catered for well. Service users had access to several health care professionals to ensure their health care needs were met. Service users had regular contact with families both in the home and when going out and with friends at day care placements. The home provided service users with a small, domestic type environment which was very comfortable. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager needed to ensure the support plans for the service users were completed and used as a daily working document. This would ensure the service users’ needs were met in a way that suited them. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 7 Profiles and support plans needed to include all the current needs of the service users and details of how these needs were to be met. To ensure the safety of the service users some of the risk assessments needed to be further developed to ensure they corresponded with details on the care plan, they needed to be regularly reviewed and include clear strategies for managing risks. Planned activity programmes should be developed with service users and/or their representatives to reflect activities of service users choice and support and encourage development of service users interests and skills. These should be subject to regular reviews. There needed to be detailed care plans in place for service users in relation to any advice given by health care professionals to ensure the advice was followed. The medication administration system needed to be improved so that the residents got their medication as prescribed by the doctor. Any incidents of challenging behaviour and their management must be clearly detailed so that they are not misconstrued as abuse. The manager needed to ensure the service users’ personal allowance was used appropriately and in their best interests. The manager needed to undertake an audit of all training appropriate to the service, to include mandatory and specialist training required to adequately support service users with their needs. There needed to be a quality assurance system in place, that supported service users to feel confident that their views underpin all self-monitoring, reviewing and development of the home. 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. Great Wood Road, 1 DS0000016922.V315722.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 Great Wood Road, 1 DS0000016922.V315722.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 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users had the information available they needed to make an informed choice about where they lived. The assessment procedure ensured that staff knew service users’ needs and that the home could meet them. EVIDENCE: As at the last inspection the service users who live at Great Wood Road had been there a number of years and there were no current plans for anyone to move on, or any new service users to move in. A service user guide had been developed for the home and this included all the required information for service users and their relatives/ representatives. It included pictures for those who were not able to read the written text and stated that it was also available on tape. It was strongly recommended that the guide be made available in larger print and spread out more to make it easier to understand. Since the last inspection all the service users had been reassessed by social care and health as their original assessments were out of date. From these assessments and the staff’s knowledge of the service users’ needs new profiles had been drawn up detailing their individual needs and how these were to be Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 10 met by staff. Work was also underway to develop individual support plans for the service users. Great Wood Road, 1 DS0000016922.V315722.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 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems in place for care planning need to be further developed to ensure the current needs of the service users are detailed and are reflected from their point of view. To ensure the safety of the service users there must be clear risk assessments in place that are reviewed and updated as necessary. Service users were assisted to make decisions about their lives wherever possible. EVIDENCE: Two service user files were sampled during the course of this inspection. A lot of work had been undertaken since the last inspection to update the care plans and risk assessments. Each of the files sampled included a very comprehensive service user profile which included details of personal care, communication needs, mobility and any aids needed, relationships, cultural needs and so on. Staff had taken a lot of time to ensure as much detail as possible was included. For example, ‘can understand simple instructions’, ‘will push things aside if she does not like Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 12 them’ and the particular sign language/gestures used by the service users were detailed. One service users’ cultural needs were also very well detailed. At the time of the last inspection there were no details for staff on the needs of the service users at night and all were checked throughout the night. This had been addressed and individual nighttime needs were detailed in the profiles and they included the support needed by night staff, for example, frequency of night checks. It was noted that since one of the profiles had been drawn up there had been some changes to the behaviours of one of the service users and this had not been updated. The manager must ensure that all profiles reflect the current needs of the service users. The profiles indicated where a risk assessment was in place for a particular activity or task. They also referred the reader to the support plan. The support plan was intended as the daily working document that detailed the service users’ needs from their perspective and how staff were to meet the needs. The support plans were not complete at the time of the inspection. When complete the support plans will meet with the recommendation that; in line with the governments strategy in learning disabilities, outlined in the white paper ‘Valuing People’ all service users are supported to have a Person Centred Plan. There was no evidence seen that the service users or their relatives/representatives had been involved in or consulted about their profiles or support plans. Service users in this home had complex needs and were reliant upon staff to interpret their non-verbal communication to ensure their needs and wishes were met. During the inspection staff were observed to be working along these lines with service users and encouraging them to make choices. There was lots of symbolised information within the home including a photo board for service users detailing what staff were on duty each day. Staff were also seen using pictures to identify what one of the service users wanted to eat. The information recorded in the daily diaries had been improved since the last inspection. There was evidence of the care offered to the service users, the care received and their responses to their care. For example, where activities were offered and declined by a specific response this was well detailed. There was ample evidence that service users were able to make decisions about their lives and staff assisted this wherever necessary. Several risk assessments had been put in place for the service users since the last inspection. The detail in these varied greatly, some were very comprehensive others needed to be further developed. Manual handling risk assessments were well detailed and specified all the equipment needed by the service users for any handling, any sudden movements that may hinder transfers and so on. There were well detailed risk assessments for such things as finance, going swimming, fire at night, alcohol consumption, the use of Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 13 kitchen equipment and holidays. Some other risk assessments needed to be further developed or reviewed. For example, one was in place for a service user to prevent scalds from hot drinks but the individual had sustained a scald and there was no evidence that the risk assessment had been reviewed. Another for challenging behaviour stated staff should keep calm and keep their distance but if the behaviour persisted staff to assist the service user home but it did not state how they were to approach at this point. Another stated that if staff were not present when the person was bathing they may be at risk but the care plan stated staff must be present at this time. Risk assessments were being cross referenced to service users’ profiles and support plans. They also included read and sign sheets indicating staff would bring to the attention of the manager any concerns. The date of implementation and review were also included. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 14 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): 11,12, 13, 14, 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. Service users were able to take part in age, peer and culturally appropriate activities but these needed to be better planned and regularly reviewed to ensure they met the service users needs. Service users were able to maintain contact with family and friends. The meals at the home were varied and nutritious. EVIDENCE: The new service user profiles included lists of what the service users liked to do socially and where they needed support. There were also details of the types of household tasks the residents could take part in as part of their personal development, for example, making drinks and snacks and how they could choose their meals. As stated previously when the support plans are completed these will be much more clear in relation to the personal development of the service users in specific areas. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 15 The cultural background of one of the service users was clearly detailed and stated how staff were to support the individual with the social needs in relation to this, for example, reading from appropriate books, cultural celebrations, appropriate day care placement and diet. Daily records evidenced that these guidelines were being followed. There was evidence in the daily records of one resident being offered activities out in the community but refusing to take part despite the best efforts of staff. There was evidence that residents went swimming, shopping and trips out to places such as the Botanical gardens. The day service for one of the residents had been stopped as they felt they could no longer support her. The home had worked with social care and health to try and find another day service but this had not been possible at the time of the inspection. There was evidence on the individual’s daily records that the family had been asked to write to social care and health about this to try and speed up the process. The manager stated that the activities for the residents were organised on a weekly basis and put in the diary. There were activity plans on the personal files sampled but for one of the service users there were only two entries for the week. This was an issue at the last inspection as activities were quite erratic and were not being reviewed by key workers. This issue was ongoing. There needed to be individual weekly planners for each of the service users that reflected their likes and dislikes and were reviewed regularly. Service users had regular contact with families both in the home and when going out and met friends at day care placements. Some work had been undertaken in relation to demonstrating how the rights and responsibilities of the service users were recognised when drawing up the profiles. These included details of how they were involved in the security of the building, if they wanted their rooms locked and how their privacy and dignity were to be upheld in relation to personal care and having time alone. It was evident from the daily records that staff would encourage service users to take part in activities but if they refused this was respected. Again these issues will be further enhanced with the completion of the support plans. Food records were being kept and these evidenced a good variety of meals being offered to the service users. There were lists of the likes and dislikes of the service users and a folder of pictures to help service users choose their own meals. There was evidence that the cultural needs for one of the service users in relation to diet were being met. At the time of the inspection one of the service users was unwell and quite frail and food and fluid charts for recording intake had been put in place however staff were not recording on these appropriately and sometimes both food and fluid were on the same chart. This made it difficult to track exactly what the service user was eating and drinking. Great Wood Road, 1 DS0000016922.V315722.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 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The support plans in the home needed to be completed to ensure service users received their personal care in the way they preferred. The monitoring of health care needs and compliance with professional advise needed to be improved. The system for administering medication needed to be improved to ensure the safety of the service users. EVIDENCE: The support the service users required in relation to their personal care varied a great deal. There was extensive detail in the two profiles sampled of how staff were to support service users with their personal care and of what they were able to do for themselves. For example, one profile gave detail of how the service user preferred to be woken, the order of dress and the position of the bed. The profiles referred to the support plans which were not completed. The manager needed to ensure that the support plans included all the detail in the profiles so that they could be used as a daily working document. From the recordings made in relation to health care professionals it was evident that the service users accessed a range of professionals. These Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 17 included doctors, physiotherapists, dentists, incontinence nurses and speech and language therapists. Some issues arose in relation to tracking how information from health care professionals or new care regimes were monitored and passed onto staff. For example, one service user had very clear instructions towards the back of her file from the speech and language therapist but this had not been included on the care profile and there was no separate care plan for this. This included details of the importance of staff being consistent but it could not be evidenced that this was being carried out. There was advise from the incontinence nurse that had no corresponding care plan and was not in the service users profile. One service user had an activity plan in place for a physiotherapy programme but it was not clear from this when or how often this was to be carried out. Residents were being weighed on a regular basis which was an improvement since the last inspection. It was noted that two accidents had occurred that may have resulted in the service users sustaining an injury and although accident forms had been completed there was no mention of these in the daily recordings. The manager needed to ensure that any accidents were in the daily recordings if only a mention directing the reader to the accident forms so that they are aware that the effects of an accident may be evident later. It was pleasing to note that one of the service users who was unwell was receiving all the appropriate care and attention from health care professionals as necessary. The family of the service user were very involved in her care also. On the day of the inspection a multi disciplinary meeting was being held to decide how best to care for the service user. One of the service users did not receive any medication. The other three service users had individual storage in their bedrooms and medication was administered via a monthly monitored dosage system. Some discrepancies were found when checking the medication, for example, a tablet that had been signed for as administered was still in the box, one lot of medication had not been acknowledged as received on the MAR (medication administration record) chart, the amounts of medication left in the home did not always correspond with the amounts received and what had been administered. Copies of prescriptions were being kept. It was also noted that since the last inspection risk assessments had been put in place where service users needed support taking their medication or may refuse. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 18 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. There was an appropriate complaints procedure and this was available in the service user guide for service users and their families or representatives. To ensure the protection of the residents the manager must ensure that their personal allowance is used appropriately. EVIDENCE: There was an appropriate complaints procedure in place and it was included in the service user guide. The home had had no complaints and none had been lodged with CSCI. The protection of the residents had improved in that several risk assessments had been put in place to ensure their safety. There was a risk assessment in place for one service user in relation to challenging behaviour and as required at the last inspection the intervention techniques were clearly detailed. However it was not clear who had authorised the techniques and also when staff were recording the incidents the wording sometimes used could have been misconstrued as neglect, for example, ignored. The manager needed to ensure that all incidents of challenging behaviour and their management were recorded appropriately. The home were managing money on behalf of the service users. The records for two of the service users were sampled. The service users were unable to sign for their own money at the bank therefore the manager and deputy had to sign for any withdrawals. The service manager stated they were trying to set Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 19 up another system where with an identification card the residents could be taken to the bank to draw their own money. The banks had not agreed this as yet. There were clear records of the income and expenditure for all money. Receipts were available for all expenditure and there were two staff signatures. It was noted that for one service user whose needs had increased the personal allowance had been used to purchase extra linen, this is not acceptable and should be part of the fees paid. Also service user’s personal allowance had been used for taxis fares for staff to support the service user whilst in hospital. Again this is not acceptable. The service manager stated that this would not normally happen and that she would ensure the money was reimbursed. The manager must ensure she is aware of the organisation’s policies in relation to the use of service user’s personal allowance. The policies and procedures for adult protection were not viewed at this inspection. Staff had received training in the protection of vulnerable adults. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improvements made since the last inspection ensured the service users had a safe and comfortable place to live. EVIDENCE: Great Wood Road is a purpose built home for service users who have complex needs and physical disabilities, the shared areas provide lots of room for moving about and all service user accommodation is on the ground floor. Several improvements had been made to the environment since the last inspection. The communal areas consisted of an open plan lounge and dining area and these were adequately decorated and furnished. The garden area had had the privacy screening improved and the uneven paving had been made safe. There was seating available for service users in the garden. The graffiti on the outside of the home had been removed. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 21 The bedrooms were nicely personalised and reflected the individual service users’ interests. Two of the bedrooms had been redecorated and two bedrooms had had new furniture as required at the last inspection. No issues were raised at this inspection in relation to dirty carpets or odour control. The bathrooms and toilets were fitted with specialist equipment to meet the needs of the service users and were large nicely decorated areas. One of the service users had a freestanding hoist and pressure equipment was obtained as necessary. One service user was using bedsides and an appropriate risk assessment was in place. The first floor of the home provided office space, a sleeping in room and bathroom for staff. The home was clean and odour free on the day of the inspection. It was noted that there were foods stored in the fridge that had not been dated when opened. Some personal toiletries had not been returned to individual service users’ rooms after use. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 22 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, 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. Adequate numbers of staff were on duty to meet the needs of the service users. To ensure staff are equipped with all the necessary skills and knowledge to care for the service users there must evidence on site of all up to date training. The recruitment procedures were robust and protected the service users. EVIDENCE: There had been quite a high staff turnover at the home since the last inspection. The manager was in the process of employing new staff to fill the vacant posts. The rotas indicated that appropriate numbers of staff were on duty to meet the needs of the residents. Staff spoken with knew the needs of the residents and relationships between them were good. Staff training records had been forwarded to CSCI following the last inspection and some staff files were sampled. There was a comprehensive training programme provided for the staff by the organisation, in the areas of LDAF, Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 23 Care of Medicines, Person Centred Planning, HIV/AIDS awareness, Understanding Sexuality, Diabetes, Epilepsy/Rectal Diazepam, Adult Abuse & Protection, Patient Care Handling, Support Plan Training, Autism Awareness, Key Working & Care Planning, Advocacy, Essential Lifestyles Planning and Communication at Work. It did not appear that the training records were up to date as some subjects had either not bee covered or were due to be updated. The manager was advised that she should devise a training matrix for all staff at the home to identify who had undertaken what training and when it was undertaken. The induction records for two fairly new staff were sampled. These were not complete. Induction for new employees must be in line with the standards and time specifications laid down by skills for care. Staff files evidenced some supervision sessions were taking place but these were not up to the required level of six sessions per year for each staff member. The recruitment files for two staff were sampled and included all the required information and documentation including, two written references, CRB and POVA first checks. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 24 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home had improved since the last inspection but further improvements were needed to ensure the residents’ needs were safely met. EVIDENCE: Since the last inspection the manager had been registered with the CSCI. She was undertaking her NVQ level 4. Numerous improvements had been made at the home since the last inspection and it was evident the manager and staff team had worked hard to meet many of the requirements made. Some areas required further improvement, for example, risk assessments, support plans needed to be in place and the management of service users’ money needed to be improved. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 25 The service still had no quality assurance system in place, a quality audit needed to be developed; that supported the service to produce an annual report. This should involve all interested parties including, service users, relatives and/or carers, staff and involved professionals. This will ensure the service is reviewed and developed to look at how best to support the service users involved. Health and safety were generally well managed. However as stated previously it was difficult to determine if staff all had up to date training in safe working practices. Notification to the CSCI of incidents and accidents in the home had improved. As at the last inspection water temperatures were checked weekly and recorded as completed, it was noted that temperatures in the shower and bathroom were lower than the 43 degrees c. required. This issue must be resolved. The in house checks on the fire system were up to date and the records stated that all the requirements made following the fire officer’s visit had been met. The electrical wiring in the home had been checked but was stated as unsatisfactory. There was no evidence to suggest that the work identified as needed had been carried out. Great Wood Road, 1 DS0000016922.V315722.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 3 2 3 3 3 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 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 1 X X 2 X Great Wood Road, 1 DS0000016922.V315722.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 YA2 Regulation 4 Requirement The registered person must produce an admissions policy, including emergency admissions. Timescale for action 01/12/06 2. YA5 5(b)(c) (Previous timescale 01/05/05 of 01/05/05 not. Timescale of 01/07/06 not assessed for compliance at this visit.) The registered person must 01/12/06 ensure a contract is developed for each service user detailing the terms and conditions of their stay in the home, this must include details of fees payable and what arrangements are in place to provide service users with annual holidays. (Previous time scale of 01/07/06 not assessed for compliance at this visit.) Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 28 3. YA6 17(1)(a) Sch3 The manager must ensure the support plans for the service users are completed and used as a daily working document. Profiles and support plans must reflect the current needs of the service users. There must be evidence that service users or their relatives/representatives have been involved in or consulted about their profiles and support plans. (Previous time scale of 01/07/06 not met.) Risk assessments must be further developed to ensure: They correspond with the needs detailed on the care plan. They are reviewed when the detailed actions do not minimise/eliminate the risk. 01/12/06 4. YA9 13(4) 01/12/06 5. YA12 16(2)(m,n) They include clear management strategies for any challenging behaviours that detail how any behaviours are brought to a satisfactory conclusion. The registered person must 01/01/07 ensure planned activity programmes are developed with service users and/or their representatives to reflect activities of service users choice and support and encourage development of service users interests and skills. These should be subject to regular reviews. (Previous time scale of 01/11/06 not met.) Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 29 6. YA17 12(1)(a) 7. YA18 12(4)(a) 8. YA19 12(1)(a) The registered person must ensure that where food and fluid charts are in use they are appropriately completed. The registered person must ensure that support plans indicate service users needs and wishes in the area of the care they receive. (Previous time scale of 01/11/06 not met.) The registered person must ensure that there are detailed care plans in place for service users in relation to advice given by health care professionals. There must be documented evidence that any care plans put in place in relation to health care are followed by staff. The registered person must ensure there is a system in place to ensure all staff are aware of any accidents the service users have had. The registered person must ensure consent forms re the administration of individual’s medication are put into place. (Previous time scale of 01/08/06 not assessed for compliance at this visit.) Medication must not be signed for unless it has been administered. All medication must be acknowledged as being received into the home on the MAR charts. The amounts of medication left in the home must correspond with the amounts received and what has been administered. 01/12/06 01/01/07 01/12/06 9. YA19 12(1)(a) 01/12/06 10. YA20 13(2) 20/11/06 Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 30 11. YA21 3(3)(g) 12. YA23 13(7)(8) The registered person must ensure that service users are individually supported to develop plans around their wishes in the event of illness and or dying. This will ensure service users wishes are meet and at this sensitive time and that staff are able to support service users with respect. (Previous time scale of 01/11/06 not assessed for compliance at this visit.) The registered person must ensure, the use of distraction and breakaway techniques as an intervention for a service user includes details of who authorised this. Any incidents of challenging behaviour and their management must be clearly detailed so that they are not misconstrued as abuse. The manager must ensure she is aware of the organisation’s policies in relation to the use of service users’ personal allowance. Personal allowance must not be used to fund taxis for staff to support service users who are in hospital. Personal allowance must not be used for extra linen when the needs of the service users’ increase. 01/12/06 01/12/06 13 YA23 13(6) 01/12/06 Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 31 14. YA26 23(2)(c) The registered person must ensure service users bedrooms are provided with furniture as detailed in standard 26. Any divergence from this standard should be fully documented in individual files and subject to periodic review. (Previous timescale 01/04/06. Requirement not met. Timescale of 01/06/06 not assessed for compliance at this visit.) All foods stored in the fridge must be dated when opened. Personal toiletries must be returned to service users’ bedrooms after use in the bathrooms. The registered person needs to ensure regular supervision and appraisals take place and that during these process, staff roles and responsibilities are looked at in respect of the work they are doing on a daily basis to support service users with their needs. (Previous time scale of 01/11/06 not fully assessed for compliance at this visit.) 01/02/07 15. YA30 13(3) 20/11/06 16. YA31 18 01/11/06 Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 32 17. YA35 18(1)(a,c) The registered person needs to undertake an audit of all training appropriate to the service, to include mandatory and specialist training required to adequately support service users with their needs. An up to date training matrix needs to be forwarded to CSCI indicating, all courses offered to staff, when refreshers are due and who is providing the training. 01/01/07 18. YA35 18(1)(a) 19. YA36 18(2) (Previous tie scale of 01/08/06 not met.) All new staff must undertake 01/01/07 induction training in line with the specifications laid down by skills for care and completed within 12 weeks of starting their employment. The registered person must 01/12/06 ensure that staff receive regular supervision, at least a minimum of six times per year. 20. 21. YA37 YA39 (Previous timescale 01/06/05 and 01/06/06 not met.) 9(2)(b)(i) The manager must be qualified to NVQ level 4 in care and management or the equivalent. 24 The registered person must (1a,b)(2)(3) ensure a quality assurance system is put in place, that supports service users to feel confident that their views underpin all self-monitoring, reviewing and development of the home. (Previous time scale of 23/10/06 not met.) 01/06/07 01/03/07 Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 33 22. YA42 23(2)(p) The registered person must ensure it is evidenced that remedial action is taken in connection with water temperatures, where it is noted they are considerable lower than expected, particularly in the bathroom and shower areas. (Previous time scale of 01/07/06 not met.) Evidence that the required remedial works on the electrical wiring in the home has been completed must be forwarded to the CSCI. 01/12/06 23. YA42 23(2)(c) 01/12/06 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 It is strongly recommended that the service user guide is made available in larger print. Great Wood Road, 1 DS0000016922.V315722.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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