Inspection on 25/05/06 for 1 Great Wood Road

This inspection was carried out on 25th May 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 41 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 24/10/06

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 Alison Stone Unannounced Inspection 25th May 2006 09:00 Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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.V288933.R01.S.doc Version 5.1 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.V288933.R01.S.doc Version 5.1 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 9th March 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, which offers no privacy for service users. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a two week period and included fieldwork, the visit to the service was carried out over the lunch time and afternoon of one day, by two inspectors. The inspectors collected information to form the basis of judgements in this report in a number of ways; they spoke to relatives of the people who live there, the manager, a member of staff and the service manager. Some service users and staff records were looked at, along with records relating to the management of the home, some aspects of health and safety, medication and some policies. The inspection focused on the last requirements and recommendations made and what progress had been made towards these since the last inspection. The previous inspection was in March 2006, this inspection was one of two key inspections that will take place this year between the end of March 06 and March 07 and these inspections will concentrate on the progress made towards the outstanding requirements and the core standards. This report should be read alongside the report of the previous inspection of 09 March 2006. The inspectors would like to extend her thanks to everyone who helped with this inspection. What the service does well: The staffing levels are maintained by a permanent staff group, shift cover in unforeseen circumstances like sickness, can be provided for by the reserve staff group and by making use of staff from other homes, therefore there is little or no need to use agency staff. The acting manager says that although they have had staff level recently, they are well supported by consistent reserve staff. The service is supported by an acting manager; she has been in post 18 months and will be applying for her registration with CSCI as the permanent registered manager by the end of July 06. The downstairs communal area has been re-carpeted providing a more pleasant area for the service users to enjoy. The staff support people to have the personal support they require in a way that they choose and enjoy supporting them to take part in activities. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 6 The staff have established relationships with the people who live there and from these relationships, they are able to use their personal knowledge to work in a positive way with people. Since the last inspection people have been encouraged and supported to take part in more activities of their choice. All the people will be supported to have a holiday this year. What has improved since the last inspection? What they could do better: Little progress has been made towards the outstanding requirements made at the last two inspections of October 05 and March 06, whilst some work has been undertaken towards these requirements, there remains serious concern about the length of time many of the requirements have been outstanding. The area of planning people’s care and supporting people to take risks as part of their ordinary life are of a particular concern to CSCI. To this effect a letter of serious concern has been sent to the organisation, requesting that they tell us what steps they are going to take to ensure the problems around peoples care is quickly dealt with. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 7 The organisation responded to this letter very quickly, setting out all the things they are going to do to make sure the problems identified of serious concern in this are addressed. 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. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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.V288933.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is still not a Service User Guide in place, so service users are not supported to have the information they require to make an informed choice. Prospective service users will know that the home will meet their needs because they will be supported with a series of introductory visits to the home, before making a decision to live there. New service users are not given enough information about the home and therefore do not know what they can expect from the service. EVIDENCE: The service users who live at Great Wood Road have been there a number of years and there are no current plans for any one to move on, or any new service users to move in. The acting manager and service manager confirmed at the last inspection any new service users would be supported with introductory visits to the home and their needs would be assessed. There is a Statement of Purpose in place, but the Service Users Guide is still to be developed. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 10 The current service users were all supported with an assessment by Social Services, however these are now out of date and full reviews of these plans need to take place, from these updated assessments of all service users current needs up dated plans should be developed. The acting manager has still not completed work to ensure all service users are supported to have individual contracts, which detail the terms and conditions of their stay and what services are provided by the organisation for these fees. The contract needs to include what arrangements are in place to support service users to have at least an annual holiday, and how this will be funded. It should detail what service users are expected to contribute, what financial support the organisation offers and what staffing arrangements are in place. Although it was noted that the acting manager said that the previous issues around service users not having an annual holidays is now resolved. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users cannot be assured their changing needs and personal goals are reflected in their individual plans. Service users are not offered every assistance to make decisions about their lives. Service users need more support to ensure they participate as much as they are able in all aspects of life in the home. Service users are not supported with risks appropriately; this could lead to service users being at risk. Service users can be confident that information about them is handled appropriately and their confidences kept. EVIDENCE: Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 12 Service users in this home have complex needs and are reliant upon staff to interpret their non-verbal communication to ensure their needs and wishes are 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. Three of the four service users files were looked at as part of this inspection. Little or no further work had been undertaken in service users files to develop care plans and risk assessments, which is of a concern. Staff meeting minutes detailed that issues with service users were picked up on by staff quickly and identified areas of concern or risk, however it was noted during the inspection that in two areas, medication and service users being at risk from scalds the work had not been undertaken to ensure plans were in place to manage these risks. However it was clear from the staff meetings that these concerns had been discussed with the staff. A relative spoken to raised concerns that risks of scalding to service users from hot drinks was a worry to her, and that her daughter had been scalded by a hot drink recently. As detailed in the last report of March 06 it is required that care plans and risk assessments be expanded upon, to include all details of service users needs and preferences and these have clear details on them of all the actions staff must take to meet needs and manage risks. Care plans should be cross referenced with risk assessments, clearly directing the reader from one to the other, ensuring service users are enabled through this process receive a full package of care. It is required that where possible service users be involved in their plans of care, where it is not possible to involve service users involving relatives/carers and/or a service users representative is required. 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 remains outstanding. As stated in the last inspection this would support service users to feel confident that their aspirations and needs are recognised and met. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 13 The acting manager said that the work required from the last two inspections, to ensure a risk assessment is put into place for the use of bed rails has been completed, however the acting manager was unable to locate it during the inspection. The service manager said that the acting manager was booked on an accredited risk assessment course and would be undertaking this course shortly. There is still in place the system to review service users plans of care every 8 weeks by the key workers and the form for completing these is an extensive document. However it was noted on two service users files looked at, that these are still not being completed. This needs to be addressed and regular key worker meetings should be offered to service users. Daily records were sampled for all the service users, whilst they are legible; some entries remain poorly written and difficult to read. They also lack information on a regular basis about what service users did during the day, on one service users records looked at, these records did not correspond with the diary which had recorded activities the service uses had taken part in. A lot of the information in the daily entries was very basic and this would make it difficult to review service users care, as the records of daily activities are not extensive. It was also noted that night staff are regularly recording that they do two hourly checks on the service users, however there is no assessment in place to say this is required nor any care plans or risk assessments around night time care for service users. This needs to be addressed and assessments should be undertaken to ascertain what the service users needs are around support at night, from these assessments, if it is identified service users need support care plans and risk assessments should then be developed. During the inspection it was noted that staff were respectful towards service users, appeared knowledgeable about service users needs and enjoyed warm and positive relationships with them. All information pertaining to service users and the running of the home was stored appropriately. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in age, peer and local activities. However work is required work to ensure activities are the service users choice. Service users are supported to maintain relationships with their family and friends. Service users rights and responsibilities are not respected and recognised in their daily lives. Service users are supported with a healthy diet and they enjoy pleasant mealtimes. EVIDENCE: Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 15 All the service users have complex needs and require full staff support to access their local community. The acting manager said the staff work hard to take the service users out on a regular basis in their local community. Activities for all service users are recorded in one place in a diary, the month of May 06 was looked at and it was seen that service users took part in going out to the local shops, attended church, going to the cinema, going to the local garden centre then did some planting at the house, going to Cannon park and had been to a disco. Whilst the inspectors were there, one of the service users was supported to go out to hydrotherapy, as the staff were working with her to eventually re establish swimming as a regular activity, this activity had taken a long time to set up and the staff have worked her family to support her with this. The acting manager said that one of the service users day service was stopping, as the day centre had reviewed it service and no longer felt able to support this service user. The organisation was working with social services to request that the funding for this service be transferred to them so that the staff at Great Wood Road could support her with daytime activities. There remains an outstanding issue with providing the service users with a car that they can use to access activities, currently service users spend their mobility allowance on taxis and the community facility ‘ring and ride’ to enable them to go out and about in their local community. However service users financial records indicated that they spend a considerable amount on a weekly basis on taxis, the acting manager clarified that where the service users go out with staff to do house shopping the organisation pays the taxi fare. It is a concern that it was again noted on this inspection that activities for service users remain ad hoc and that the assurances given by the acting manager at the last inspection in March 06; that this would be addressed at the 8 weekly reviews by key workers has not been completed. Key workers also need to support service users to develop likes and choices around activities and develop individual weekly planners for each of the service users, these should then be reviewed regularly. All service users files lacked lists of activities they liked and disliked, in the absence of planning and reviews of activities it is difficult to determine how staff can develop service users interests and support their personal development in this area. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 16 Although some work has been undertaken in this area and it was noted that one-service user had a photo diary on his wall, telling him about his weekly activities. The acting manager said that she and the staff encourage the service users to have and maintain good relationships with their families/relatives and there is regular contact between service users and their families. Relatives spoken to said that they regularly visit the house and staff keep them informed about any problems regarding their relatives. Service users maintain relationships with their friends through their attendance at the local day centres. Given the lack of information in service users files, around regular key worker meetings, the lack of a quality assurance system and an absence of planning for service users it was difficult to see how and if service users were supported to have their rights and responsibilities respected and acted upon. The acting manager has now ensured that all service users have been referred to the dietician, for advice and guidance to support them with a healthy diet. Menus indicated a relatively well balanced diet that offers service users a choice of meals. Staff ensure that service users meal choices are recorded on a daily basis. The dinning room is a pleasant area with lots of light with suitable facilities to support service users with their needs around meal times. One-service user was observed having her lunch and it was noted that staff discreetly supported her with her needs during this meal. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in the way they prefer and require their independence and dignity is promoted, this requires further development. Service users physical and emotional health needs are generally met. Service users are supported and protected by the home’s policies and procedures with the administration of medication. Service users cannot be confident that their individual wishes will be met in the event of aging, illness or dying. EVIDENCE: Little further work had been undertaken in care planning, existing care plans detailed the preferences of the service users and what support they would require to some extent. This work has now been outstanding 11 months and needs to be completed. Care plans/support plans for individuals need to detail the preferences of service users to ensure staff provide care in a way that reflects service users needs and their choices. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 18 It could be demonstrated in the service users files that service users are well supported with their health needs, accessing a range of medical appointments supported by staff, to ensure their health and well being. However it was of concern that it was noted during the inspection that a service user had, had an issue with refusing medication and she had not been supported appropriately to ensure she received the medical advice in a reasonable time scale. It was noted that another service users had an oral health issues, described as marked issues on the file, it was a concern therefore that there was no care/support plan in place to support the individual with their needs in this area. Whilst there were few concerns about the staff supporting the service users with their health needs, it is important to ensure all the service users be supported to have individual Health Action Plans, as detailed in the Governments National Strategy, out lined in the white paper ‘Valuing People’. This would prevent any health issues being overlooked and support staff to be proactive in the care of service users health needs rather than reactionary. It is of concern that service users are still not being supported to have their weight regularly monitored, this should be completed at least monthly. It was noted on one service users file that their weight was last recorded as being monitored on the 31 October 2005. It is important service users weight be regularly checked, as weight loss or gain can be indicative of underlying health issues that would need further investigation. It was noted that the requirement to put in place assessment of service users skin care needs had not been undertaken since the last inspection and there were no care plans for any of the service users in this area. As stated in the previous inspection it is required that all service users be supported to have individual assessments to ascertain what risk if any, service users are at from skin soreness and/or breakdown. This is particularly relevant to service users with any weight issues, mobility problems and/or incontinence. There has been a drug error since the last inspection, this situation was thoroughly investigated and appropriate action was taken. Regular audits of medication are undertaken. Medication was found to be safely stored in service users rooms, this method of storing medication reduces the possibility of errors, consent forms need to be put into place for all service users in respect of administering medication. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 19 Where appropriate staff should be provided with guidelines on how to support service users with the administration of their medication. Work needs to be undertaken with service users and their families to ensure plans are made that reflect service users wishes in the event of illness and dying. To ensure service users are treated with respect and their needs and wishes met. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be generally confident that their views are listened to and acted upon. Service users cannot be confident that they are protected from neglect and self-harm. EVIDENCE: The complaints policy was seen in the home, this had CSCI relevant contact details. It was noted that each service users had an accessible post-card in their rooms, detailing how to make a complaint. The service manager said that the complaints policy was also available in a tape cassette to service users. There have been no complaints since the last inspection. It remains an outstanding recommendation that key workers undertake individual work with service users supported by the speech therapist to support them to understand their rights to complain under the complaints policy. Again it remains an outstanding recommendation that where this is difficult given the service users complex communication needs, that service users family/relatives be involved in this process, this should be then documented on service users files. The acting manager said that all staff have now received Vulnerable Adult Protection Training, this was looked at in staff records and it was noted that Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 21 certificates were not in place in this respect. The acting manager assured the inspectors this training had been undertaken and they were waiting on certificates to come through for staff. There were policies in place within the home in respect of the protection of Vulnerable Adults and staff files inspected indicated current Criminal records checks in place. However as described in the outcome section “Individual Needs and Choices” and “Personal Health Care and Support”, risks to service users and health needs have been identified and appropriate action has not been taken. A letter of serious concern was sent to the Responsible Individual in this respect. The lack of a current assessments for each individual and the absence of up to date care plans and risk assessments, remains a serious concern, this concern is increased given the length of time this requirement has now been outstanding. Failure to meet these requirements continues to place service users at risk. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to live in a comfortable safe environment, that is clean and hygienic. Service users bedrooms are pleasantly personalised and reflect their interests and promote their independence. Bathrooms provide service users with a pleasant private area, which meet the individual needs of the service users. There is ample shared space for service users to enjoy and relax in. EVIDENCE: A tour of the premises was undertaken as part of the inspection process, including the outside areas. 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. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 23 The carpets in the lounge and dinning room have just been replaced and the bathrooms are fitted with specialist equipment to meet the needs of the service users and are large nicely decorated areas. However a programme of redecoration and refurbishment needs to be undertaken. Bedroom carpets need cleaning as they are heavily stained or replacing if cleaning does not remove the stains. All the woodwork throughout the house needs re-painting as much of it is chipped and marked, as required in the last inspection the refurbishment schedule needs to include the service users bedrooms as these are still in need of decorating. In two of the service users bedrooms it was noted that, in one bedroom the wardrobe and set of draws were dirty and marked, and in the other bedroom the service users draw unit was broken, it is required that these pieces of furniture be replaced. Bedrooms were noted to be individualised and reflect the service user interests and many of their personal effects. It is a concern that the work to the outside of the premises identified as being required in the last two inspections has still not been completed, the uneven paving stones in the front garden need replacing and the screening of this area to provide service users with a private area to relax in still needs to be completed. The gates at the back of the house have prevented the problems with vandals, but it was noted that there is still graffiti on the walls at the back of the house that needs to be removed. It is recommended that these gates be screened with planting to provide some privacy for the service users. The staff are provided with an office space, a sleeping in room and bathroom facilities on the first floor, these areas are also in need of redecoration. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are supported with their roles and responsibilities, and are generally an effective staff team. Service users are protected by the recruitment policy and practices in place. Staff are not appropriately trained and supervised. EVIDENCE: The acting manager said that the home benefits from regular staff meetings where staff roles and responsibilities are discussed along with issues pertaining to service users. Staff meeting minutes were looked at as part of the inspection process and they were found to happen regularly and be comprehensive in nature, problems were clearly identified in the meetings and there was evidence of follow up action being required. The service manager continues to support the acting manager in her role, a role that she has now been in for 18 months. It was discussed at the inspection with the acting manager and the service manager, that an application must be submitted for the acting manager to be registered as the manager of the service. The time scale for this is before the end of July 06. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 25 The service manager has written to CSCI in response to the last inspection report, detailing in a letter the formal support plan the acting manager has been offered and this is still on going. The acting manager continues to undertake work with the staff team to support them with their roles and responsibilities in the areas of the key worker role and initiating activities and personal and health care support they provide for the service users. However it was noted on the inspection little progress has been made in these areas. The acting manager now regularly works across the shift patterns on a regular basis to ensure she has an over view of the management of the staff team and the support needs of the service users. The training records for two staff were looked at. There is a comprehensive training programme provided for the staff by the organisation, in the areas of LDAF, 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. As training records were not regularly updated it was difficult to assess what training staff had actually undertaken, staff records did not indicate that all staff had attended training in the area of protection of Vulnerable Adults, however the acting manager said that all staff have attended this course but training records have yet to be up dated and she is waiting for certificates to be sent through. The organisation provides core training in Data Protection, Health and Safety, Manual Handling, Fire safety, Violence and Aggression, Equality & Diversity and a Central Induction. All new staff are supported to undertake their LDAF award and over 50 of the staff team have their NVQ 2 and the acting manager is currently undertaking her NVQ 4 in management. It is still required that the acting manager provide CSCI with a training matrix for the service, detailing what courses staff have completed, when refreshers are due, the length of the training course being provided and who is providing the training. As a good practice guideline it is recommended that a copy of all course contents detailing what is covered in the course is kept with the training file. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 26 Supervision of the staff team has generally improved, however it was noted that not all supervisions of staff are happening on the required basis of at least six times a year. Staff appraisals are still to be undertaken. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service users benefits from a generally well run home. The service needs to develop a quality assurance system, and ensure service users views underpin this process. Some areas of record keeping need to improve. The health and safety of the service users is promoted and protected. EVIDENCE: The last inspection was in March 06, many of the requirements remain outstanding and some of the requirements needing to be met by the dates identified in the last report have failed to be met. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 28 The service will be subject to a at least two further inspections this year, the second inspection which will be a random inspection which will concentrate on checking whether the service has ensured compliance with the requirements by the dates indicated in the requirement section of this report, failure to do this will lead to enforcement action by CSCI. The service still has no quality assurance system in place, a quality audit needs to be developed; that supports 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. There was much improvement in the area of record keeping, however it was noted during the inspection that the service is not notifying CSCI as required of all notifiable incidents, an immediate requirement was left in this respect. The Portable electrical Appliance Tests had been done for the year and there was a Gas Landlord Certificate in place. It was noted that there are still problems with the fridge and freezer temperatures, recordings of these demonstrated that temperatures were higher than expected guidelines. Water temperatures are checked weekly and recorded as completed, it was noted during the inspection that temperatures in the shower and bathroom were lower than the 43 degrees c. required. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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 2 3 2 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 2 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 1 3 LIFESTYLES Standard No Score 11 1 12 2 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 1 2 X 1 X 2 2 X Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 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 17(2) Sch4 Requirement The registered person is required to produce a service users guide that includes; Summary of the Statement of Purpose. Terms and conditions in respect of accommodation to be provided, including amount and method of payment. Standard form of contract Most recent inspection report Summary of complaints with CSCI contact details 2. YA2 4 Previous timescale 01/06/05. The registered person must produce an admissions policy, including emergency admissions. Previous timescale 01/05/05. The registered person must undertake the review of all service users assessments of DS0000016922.V288933.R01.S.doc Timescale for action 01/06/06 01/07/06 3. YA3 12 01/09/06 Great Wood Road, 1 Version 5.1 Page 31 4. YA5 5(b)(c) 5. YA6 17(1)(a) Sch3 needs and from this process new service users plans should be developed to ensure the individual needs and aspirations of new and existing service users are identified and met. The registered person must 01/07/06 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. The registered person must 01/07/06 develop service user plans to include: Detailed up to date care plans, which are subject to review. These must include the goals and aspirations of service users activity plans and monitoring of such. Previous timescale 01/06/05brought forward. The registered person must ensure daily diaries have more detail and must include activities/opportunities, which have been offered to service users. These records must contain details of care offered; care received and response to care. Previous timescale 01/05/06Requirement not met. The registered person must ensure it is demonstrated how service users are involved in their plans of care and where this is not possible, how their relatives or representatives are involved. DS0000016922.V288933.R01.S.doc 6. YA6 17(1) Sch3 01/06/06 7. YA7 12(3) 01/07/06 Great Wood Road, 1 Version 5.1 Page 32 8. YA8 24(3) 9. YA9 13(4) The registered person must undertake work to ensure it can be demonstrated how service users are consulted with and participate in all aspects of life in the home; this is particularly relevant in care planning, risk assessment and developing activities. The implementation of Person Centred Plans, as identified in the recommendations would support this process. The registered person must ensure further development of risk assessments is required. These include; Existing controls are crossreferenced to further action required. Risk assessments must be cross-referenced to existing policy and procedures. Risk assessments must be cross referenced to care plans, again with read and sign sheets, indicating staff will bring to the attention of the management of the home, any concerns, or changes to these. Risk assessments must contain the date of implementation and review. The review of risk assessments must include a rationale for its continuation in its present form A risk assessment must be put in place for the use of bed rails, supporting service users who are at risk of scalds, and the use of the kitchen when unsupervised. 01/11/06 01/06/06 Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 33 10. YA11 16(2)(m) 11. YA12 16(2)(m,n) 12. YA13 16(2)(m) 13. YA14 16(2)(m,n) 14. YA16 12(4)(a) Previous timescale 01/06/05. The registered person must ensure service users are supported to develop their skills as far as they are able in maximising their independence, care plans need to be put into place to support service users with this, these should then be regularly reviewed to indicate what development service users have made. The registered person must 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. The registered person must develop service users activities more and link these into activities that are planned around supporting service users in their local community. The registered person must ensure that information is available in the home of all local activities and that then work is undertaken individually with service users to identify activities they would like to participate in and they are then supported to do these. These should be regularly reviewed to ascertain individual’s interests and likes and dikes. The registered person must undertake work to look at how it can be demonstrated service users rights and responsibilities are recognised and respected in their daily lives, this includes DS0000016922.V288933.R01.S.doc 01/11/06 01/11/06 01/07/06 01/11/06 01/11/06 Great Wood Road, 1 Version 5.1 Page 34 15. YA17 12(3) issues around having a key to the front door and that of their bedrooms, how service users privacy and dignity is maintained. The registered person must ensure service users are involved wherever possible in determining meals and alternative choices Previous timescale 01/05/05. The registered person must ensure care plan are developed that indicate service users needs and wishes in the area of the care they receive. The registered person must ensure that where there are concerns about: Nutritional intake of service users, that appropriate steps are taken to monitor weight, and address any concerns to relevant professionals for advice and assistance. Previous timescale 01/05/06 Requirement not met. The registered person must ensure that where it is identified that there are health issues that may detrimentally affect a service users well being, that appropriate and timely action is taken. The registered person must ensure that where there are concerns about pressure area care or continence management, that these are referred to appropriate professionals for advice and assistance. Previous timescale 01/05/06 Requirement not met. The registered person must ensure consent forms re the DS0000016922.V288933.R01.S.doc 01/06/06 16. YA18 12(4)(a) 01/11/06 17. YA19 14(2) 15 01/06/06 18. YA19 12 01/11/06 19. YA19 14(2) 15 01/06/06 20. YA20 13(2) Sch3 (3)(i) 01/08/06 Great Wood Road, 1 Version 5.1 Page 35 21. YA21 3(3)(g) 22. YA23 13(7)(8) 23. YA24 23(2)(a) administration of individual’s medication are put into place. Also that where it is identified that service users require support with taking their medication that plans are developed to support staff in the administration of service users medication. 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. The registered person must ensure, the use of distraction and break-away techniques as an intervention for a service users who displays challenging behaviour must be written in the care plan with a description of what techniques should be employed and when it should be used. It must be subject to frequent documented review. The registered person must ensure that the garden area that offers little privacy for service users has appropriate screening or other means to address this. Previous timescale 01/06/05 – brought forward. The registered person must ensure a maintenance schedule is forwarded to CSCI with time scales clearly identified, for all the work required both inside the property and outside the property, demonstrating a programme of redecoration and refurbishment. DS0000016922.V288933.R01.S.doc 01/11/06 01/07/06 01/08/06 24 YA24 23(2)(o) 01/08/06 Great Wood Road, 1 Version 5.1 Page 36 25. YA24 23(2)(o) The registered person must 01/06/06 ensure steps are taken to address the uneven paving in the garden, which present a trip hazard Previous timescale 01/06/05 – brought forward. The registered person must ensure the two bedrooms identified as needing to be redecorated, are decorated with service users involvement. Previous timescale 01/06/05. The registered person must ensure that the graffiti on the outside walls of the house is removed. The registered person must ensure that all service users bedroom carpets are cleaned to remove heavy staining, and if this fails they must be replaced. The bedroom furniture in two service users rooms, one set that is heavily is marked and the other set where the set of draws is broken must be replaced. The registered person must ensure service users bedrooms be 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. The registered person must ensure that the bed rails used do not present a risk to the service user. The home must supply CSCI of 26. YA24 23(2)(d) 01/08/06 27. YA24 23(2)(d) 01/09/06 28 YA26 23(2)(d) 01/09/06 29. YA26 23(2)(c) 01/06/06 30. YA29 13(4) 01/06/06 Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 37 evidence of the outcome of this investigation and a copy of the risk assessment completed. Previous timescale 01/05/06 Requirement not met. The registered person needs to ensure regular supervision and appraisals take place and that during these process, staff roles and responsibilities are looked in respect of the work they are doing on a daily basis to support service users with their needs. The registered person must ensure that staff are confident in the content and provision of policies and procedures in respect of Sexuality Their role in facilitating complaints for service users Previous timescale 01/05/06. Requirement not met. The registered person needs to 01/08/06 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. This should then be followed up with individual staff to ensure that they are supported to attend any and all appropriate training. Staff files should indicate up to date records of training that has taken place. 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. The registered person must 01/06/06 ensure training be provided to DS0000016922.V288933.R01.S.doc Version 5.1 Page 38 31 YA31 18 19 01/11/06 32. YA32 18(1)(c) 01/06/06 33. YA35 18(1)(a,c) 34. YA35 18(1)(a,c) Great Wood Road, 1 all care staff to include: Hygiene and food handling Previous timescale 01/06/06. Requirement not met. The registered person must 01/06/06 ensure that staff receive regular supervision, at least a minimum of six times per year. 01/07/06 23/10/06 35. YA36 18(2) 36. 37. YA37 YA39 38. YA41 Previous timescale 01/06/05. 8 The acting manager must apply 9 to become the registered manager of the service. 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. 17(2) The registered person must Sch 4 ensure that all notifiable incidents including, refusal of medication and accidents are reported to CSCI. 13(5) The registered person must ensure that the further development required in the area of manual handling risk assessment for one service user is completed; all risk assessments in this area must be regularly reviewed for all service users. Previous timescale 01/05/06 Requirement not met. 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 DS0000016922.V288933.R01.S.doc 01/06/06 39. YA42 01/06/06 40. YA42 23(2)(p) 01/07/06 Great Wood Road, 1 Version 5.1 Page 39 41. YA42 16(2)(j) the bathroom and shower areas. The registered person must ensure that fridge and freezer temperature checks include: Action taken to address variances from the acceptable range. Previous timescale 01/05/06 Requirement not met. 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. o. 1. 2. 3. Refer to Standard YA7 YA19 YA39 Good Practice Recommendations All services users need to be supported to have a Person Centred Plan. The service users should be supported to have individual Health Action Plans. It is recommended that the manager explore how task can be delegated to staff to further facilitate compliance with requirement as well as participation and understanding of the staff team. Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 40 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Great Wood Road, 1 DS0000016922.V288933.R01.S.doc Version 5.1 Page 41 - 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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