Inspection on 07/02/06 for 10 Chapel Street

This inspection was carried out on 7th February 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 51 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Chapel Street 29/07/08

10 Chapel Street 28/02/07

10 Chapel Street 01/03/05

10 Chapel Street 31/01/05

10 Chapel Street 11/03/04

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 10 Chapel Street Quarry Bank Dudley West Midlands DY5 2DN Lead Inspector Debbie Sharman Announced Inspection 7th February 2006 09:30 10 Chapel Street DS0000024960.V281832.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 10 Chapel Street DS0000024960.V281832.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. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 Chapel Street Address Quarry Bank Dudley West Midlands DY5 2DN 01384 411153 01384 560210 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) Black Country Housing and Community Services Group Elaine Ball Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (male) identified in the variation report dated 16.12.04 may be accommodated at the home in the category of PD. This will remain until such time that the service users placement is terminated. 18th August 2005 Date of last inspection Brief Description of the Service: 10 Chapel Street is a purpose built detached property sited in Quarry Bank and within walking distance of a range of facilities including shops, health services and churches. The building is within its own grounds and has wheelchair access to the ground floor. There are two communal areas (lounge and dining room) and all service users have a single room. Some aids and adaptations are present as needed for the current resident group. The registered provider, a not for profit social landlord, offers long stay accommodation at Chapel Street to adults with a learning disability. The provider does not offer short term or emergency care at this home. The staff group, led by a new Manager, consists of one deputy, two senior support workers and eight support workers, all of whom are female, but are drawn from a variety of ethnic backgrounds. Senior Managers within the organisation monitor the management of the home with support from specialists employed for their purpose. The home does have its own minibus although there is access to local public transport links through the nearby shopping centre. Whilst the home only has limited parking there is a car park sited opposite for public use. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection meaning that the provider, Manager, staff and service users received prior notification and were able to prepare. This inspection, which was conducted by one Inspector, began at 9.30am and concluded at 6.00pm. The plan for this inspection was to assess those National minimum Standards that were Not Assessed at the previous inspection and also to assess progress made towards meeting related previous requirements issued to ensure improvement. The Manager and Deputy Manager supported the inspection process throughout the day. The Inspector was able to discuss progress and performance with the Manager and her Deputy, inspect documentation and tour the premises. All the service users were out when the Inspector arrived. It was not possible to talk to a service user during the inspection. Service users returned later in the day but one service user had returned from her day centre poorly and as a result of this combined with the disrupting effect of the inspection and the presence of the Inspector one service user was quite agitated. It was therefore agreed that the Inspector would remain as discreet as possible and on this occasion service users were not observed or interviewed. This was a positive inspection with many previous requirements met indicating progress. What the service does well: What has improved since the last inspection? There have been considerable improvements made in some aspects of staff training and the environment has undergone improvement providing a better maintained and pleasant home for service users. The kitchen has been refitted and painted. New flooring has been provided in the bathroom. A new industrial washing machine with a sluice cycle has been purchased which better supports good infection control practice. The Environmental Health Officer has inspected twice in 2005. Overhead tracking hoists that are now not used have been removed from a service users bedroom providing a less clinical feel to the room. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 6 All except one staff member has undertaken infection control training and Adult Protection training. Service users have been reimbursed where the previous inspection found that they had inappropriately funded expenses that should have been met by the home. There has not been occasion to inform the Commission for Social care Inspection of the physical restraint of service users as no such techniques have been used at the home. The requirement has however been deleted from the report on the basis that the Manager is sufficiently aware of the need to do so. Senior staff have undertaken Risk Assessment training and the Manager has successfully achieved the required National qualifications to qualify her for role. The Manager has also been provided with an up to date job description to clarify her role. In addition improvements have been made to the home’s Statement of Purpose with all omissions included. The document is now a useful document that provides service users, members of the public and professional visitors with appropriate information about the service provided at Chapel Street. Systems have improved to help to monitor health appointments and appointment outcomes. This will better ensure that appointments are not overlooked. Any bruises incurred by service users are being appropriately documented and described which improves accountability and helps to protect service users. Similarly accidents are being routinely analysed to identify trends and patterns to seek to better minimise risks to service users. A quality assurance tool has been purchased to help the home to assess its own performance. What they could do better: Systems to completely support dietary health and nutrition must improve. A service user thought to be most at risk is still not being weighed due to a lack of appropriate scales. Nutritional risk assessments are not being undertaken to measure nutritional risk for individual service users and therefore need is not known and cannot be acted upon. Pressure sore assessments must also be undertaken to reduce the risk of pressure sores arising. Dental treatment and/or advice are not known to the home, as it is believed that this service is provided at the Day Centres. Although improved, assessments and care planning therefore continue to contain omissions. Effort must now be applied to their improvement. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 7 Management time must concentrate on managing and monitoring systems. The Manager is hopeful that the newly purchased quality assurance system will support the management team to achieve this. 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. 10 Chapel Street DS0000024960.V281832.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 10 Chapel Street DS0000024960.V281832.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): 2, 5. Most but not all of service users individual aspirations and needs are assessed. Each service user has an individual written contract with the home which are to be reissued in a revised more accessible pictorial format. EVIDENCE: Most service users it appears were admitted to the home prior to the introduction of the National Health Service and Community Care Act. One was admitted after. Community Care Assessments arising from this legislation, which would have been undertaken by the placing Social Worker outlining the service users, needs are not present. The home has undertaken its own assessments, which have been reviewed. Most areas of assessed need are included in the homes assessment but there are omissions e.g. pressure sore assessments, nutritional risk assessment, holistic health assessments including specific condition related needs and specialist input. The newly purchased quality assurance tool includes a new needs assessment template, which the manager is considering using. In addition new screening for health plans have been recently provided by Dudley Primary Care Trust which when completed will help to address the omissions. The format of the contracts between the home and the service user have been reviewed and improved. The pictorial format makes the content more accessible and although these have not yet been reissued the plan is to do so. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7. Some of service users assessed and changing needs are reflected in their individual plan. Care plans are not fully guiding staff in all areas of need. Service users rights to make decisions on an immediate day-to-day basis are respected. Formal requests can be overlooked. EVIDENCE: Each service user has a care plan which is based upon the homes own assessment of need. As there are some omissions in the homes assessment of need it follows that there are some omissions in care planning. Nutritional need and risk is Not Assessed and care plans are not in place to support a service user who wishes to lose considerable weight gained. The risk of pressure sores for a service user who spends considerable amount of time in a wheelchair is Not Assessed and therefore the need for care planning for this area is not known. Behaviour care plans are still not in place. A priority behaviour management care plan is still being finalised by the Psychologists involved in providing support. The plan is that after this support the home will be able to put behaviour plans in place for others where required. It is however concerning that in the meantime these are not available. Families are 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 11 slowly becoming involved in care planning with there being evidence so far of one family’s involvement. Multi disciplinary reviews are not taking place although the Manager said these are planned. It is intended to conduct these by phone. The need for reviews is becoming increasingly apparent to ensure good communication between the home and day centres about dietary goals and dentist provision. The home believes dental screening to be taking place at the day centre but there is no evidence of this within the home who has regulated responsibility for this. Decision-making is not included within care plans but any restrictions as a result of risk are appropriately accounted for. There is good evidence of staff responding well to immediate service user requests. For example care records demonstrate that staff respond appropriately when a service user ‘requested to go to bed early’. There was no evidence that a service users request in a residents meeting for ‘more sewing and knitting’ had been met. The Manager and Deputy accepted that they need a system to help them to oversee and monitor such outcomes to ensure the validity of such forums. No service users currently have an advocate. One service user is enabled to manage her money. In spite of ongoing requirement to the contrary the Manager remains the financial appointee for service users. After consideration the provider feels there is no alternative and is satisfied that systems are in place to safeguard the service users interests and the Manager. Therefore the ongoing requirement has been deleted. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 16 There is evidence that service users take part in appropriate activities within the home and community. Systems to evaluate outcomes for service users could improve. Service users rights are respected and their responsibilities recognised in their daily lives. EVIDENCE: At this inspection there was better evidence of a service user being supported to attend a place of worship in line with her expressed wish. Activity plans are in place for individual service users. Performance was inconsistent but there is evidence of service users being supported to engage in activity both within the home and in the community. Whilst evidence showed that at times the homes activity plan had been deviated from with no explanation for this, there was some evidence that deviations had been in line with service users expressed wishes which constitutes an improvement. Activity provision could be better evaluated with improved systems needed to manage and monitor outcomes for service users as there was no evidence that requests for specific activities made by service users in residents meetings had been followed through. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 13 The management of service users rights and responsibilities is a strength of the home. There is good-recorded evidence and practice evidence that service users routines and preferences are respected and adhered to. Any restrictions, which may compromise rights, are documented and accounted for. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20. Some but not all service users health needs are being met. Service users are generally protected by the homes medication systems but the need for some further improvement is outstanding. EVIDENCE: Some health outcomes for service users are generally good although at times evidence is inconsistent and there are some significant omissions in care practice. Longstanding requirements for a service user to have his ears syringed following recorded advice from a nurse have not been met and there is not sufficient evidence as to why this has not happened. There was some discussion about this no longer being required but the situation was unclear and not backed up by recorded medical opinion. There is good evidence of GP attention being sought in the event of changes in health or condition and some but not consistent evidence that specific GP advice is being followed. There was for example evidence that advice to refrain from dairy food for a couple of days was adhered to but no evidence in food records that advice had been followed not to have meat, lettuce, tomatoes cucumber and cheese as food intake records for this service user indicated ‘as per menu’ which contained some of these products. Health screening is generally well evidenced. A service user case tracked had had an annual medication review, chiropody 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 15 treatment and a prescription following an eye test had been issued. Dental treatment is not evidenced. The manager said that this is provided at the day centres but the regulated service, Chapel Street does not have any record of appointments or treatments provided or required. Dental advice therefore is not reaching the home and this is compounded by no multi disciplinary reviews where such matters could be discussed. Hearing tests are also not being carried out. Systems to identify and support service users nutritional need are lacking. Weights are taken for most service users regularly but become meaningless if not taken in context of an understanding of nutritional risk and safe weight ranges for individuals. Also the health of a service user who uses a wheelchair is being compromised by the homes inability to take his weight. Appropriate and safe scales for his use have not been provided. The Manager has made attempts to share scales with other providers but unsuccessfully to date and this is far from satisfactory. The risks of pressure sores to this individual service user have also not been assessed. Medication practice has improved as the home has met many of the previous outstanding requirements relating to medication. This will support the health of service users and reduce the risk of error. Assessment of medication records and storage was satisfactory. The home is supported well by the supplying pharmacist who visits the home regularly to assess practice and provide advice. Senior staff have received accredited medication training and it is planned for remaining staff to undertake accredited training too. A requirement first made in January 2004 to risk assess medication administered covertly has not been met and this must now be done as a priority to protect all service users and staff. Service users at Chapel Street are not able to formally consent to the home administering medication as previously required. As the service users are adults the Manager is reluctant to accept the permission of relatives as she sees this as tokenistic and undermining of adult service users who are able to refuse medication. In the event of refusal the home would follow its procedures. The previous requirement has therefore been removed. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Service users are protected from abuse, neglect and self-harm but some written guidance to support staff in this was lacking. EVIDENCE: There have been no reportable incidents that have compromised the well-being or safety of service users e.g., no allegations, no need for disciplinary action, no restraints etc. Although local procedures and a whistle blowing policy in the event of an allegation of abuse were on the premises the homes policy had been removed for updating and was not available for inspection or to guide staff. Similarly a policy to guide staff about their involvement in will making and accepting gifts was not on the premises. The absence of behaviour plans to guide staff has been commented on earlier in the report and although this is being addressed it is for one service user only, progress is slow. Staff have been taught one restraint technique for use with one service user if required but there is a good understanding of this being a last resort measure and of the need to preferably recognise and diffuse triggers as an alternative to restraint. The trainer has written up the guidelines for the restraint. Whilst staff demonstrated the move to the Inspector and provided assurance that the wrist joint is not held during any restraint, the Inspector expressed concern that the written guidelines were worded ‘hold wrists firmly’ as this would be contrary to Department of health advice and may mislead staff practice risking the physical safety of the service user. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Service users live in a comfortable and safe environment. Day to day infection control practice has improved. Written guidance is not sufficiently available to guide staff in all aspects of infection control practice. EVIDENCE: The premises are well maintained, bright airy and clean with service records up to date although the fire equipment contractor has recommended that the alarm system be updated. The Fire Officer last visited in 2003 and it would be advisable to seek Fire Service advice about the sufficiency of the current alarm system. Premises are spacious and accommodate only 4 service users, one of whom uses a wheelchair in the property. Some considerable improvements have been made to the kitchen by refitting it and new flooring has been provided in the bathroom. The tiles, which are scratched in the bathroom, have not yet been replaced. The home does not have a maintenance programme for the fabric and decoration of the home. Both outstanding requirements to improve infection control practice have been met including the provision of a commercial washing machine with a sluice programme and a hand washbasin in the laundry. The Environmental Health Officer has visited recently to assess health and safety and food safety (March 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 18 and June 2005). The Manager said there were no requirements arising from these visits. The home does not have an Infection Control Policy. Aspects of infection control are referred to in other policies but this is not pulled together in a sufficient and comprehensive document easily accessed by staff. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35. The staff team is developing in confidence and is benefiting from improved direction and training. Ongoing improvement will better support service users. There has been good progress with many aspects of training but significant omissions remain in the homes training programme. An induction programme to induct new staff to the required standard is still not operational. EVIDENCE: Some specific training to provide staff with knowledge about the disabilities and conditions of service users has been provided e.g. challenging behaviour, communication, epilepsy awareness, nutrition, moving and handling. One service user has autistic tendencies and staff should be provided with awareness training to help them to support and understand the needs of this service user. Fifty percent of staff have achieved NVQ level 2 ensuring that the home has met the required national target by 2005. No staff who are under the age of 18 are employed but one staff member is under 21 years old. Staff who are under 21 should not be left in charge of service users. The Manager said that this staff member is indirectly left in charge if she accompanies a service user into the community. Steps must be taken to address this to safeguard both service users and the staff member. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 20 The manager does not have access to the training budget, which is held centrally. Training is also managed centrally at Head Office. Good progress has been made in the provision of mandatory staff training with positive outcomes for the first time at this inspection. A training matrix is helping to support the training programme and head office has, the Inspector was told individual training needs assessments for each staff member. Effort now needs to be concentrated on the provision of specific knowledge training e.g. autism awareness etc. Two staff attended Equal Opportunity training the day before the inspection but these were the first to attend with no dates available yet for other staff. There appears to have been a minor step forward in the quest to provide appropriate (LDAFF) induction training for new staff with the identification of an individual to train the trainer. However induction provision outcomes are not sufficiently clear to the Manager and she was not confident that new starters within the immediate future could be provided with adequate induction that meets the required standard. This continues to be very unsatisfactory, as the provider has had more than three years to ensure compliance with this Standard. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Service users benefit from a well run home. The Manager is qualified, competent and experienced to run the home and meet its objectives. Systems are not yet operational to support self-monitoring by the home and service users cannot currently be assured that their views underpin the development of the home. With a few minor omissions, the health and safety of service users are generally promoted and protected. EVIDENCE: The Manager who is registered with the Commission for Social Care Inspection informed the Inspector that she has now completed both her NVQ level 4 in Care and her Registered Managers Award and is awaiting the certification for the Registered Managers Award. The Manager has a new job description, which outlines her responsibilities to ensure that the objectives of the home are achieved. The homes registration and insurance certificates were properly 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 22 displayed as required and service users all have contracts of residence. In addition the Manager has ensured that she has undertaken periodic training and there was substantial evidence of this including eleven courses that she had completed in 2005 to enhance her skill and knowledge in a wide range of appropriate areas. Since the last inspection the home has purchased a quality assurance tool to help the service to assess and respond to the quality of the service it provides. This has not been used yet as the Manager was keen for the Inspector to see the system before completing it. A cursory look seemed to show that the tool is providing systems required for running the care home e.g. care planning formats, visitors book, waterlow assessment templates, weight record templates and needs assessment proformas. A service user satisfaction questionnaire is also included. There do not however appear to be any monitoring systems in place to assure the quality of those systems once completed. Feedback templates for third parties also seem to be omitted. A poster was displayed in the home informing service users, staff and visitors of this inspection. Two of the Commissions questionnaires were returned from relatives one of whom was satisfied that if s/he asked for a copy of the inspection report s/he would be shown it. The second respondent said that s/he was not made aware of forthcoming inspections and did not have access to an inspection report. The manager should review this. So whilst the home is not yet measuring its own performance based upon service user views, service user meetings are held regularly and detailed minutes seen provide evidence that service user views are sought and are given. There was less evidence however that the views given by service users are followed through. A robust quality assurance system must help the home to better manage this. Training to support staffs understanding of health and safety has improved. All staff except one have done moving and handling training. Al staff except one have done Infection Control Training. All staff except one has done fire training within the last 12 months. An e-mail requesting First Aid training for 6 staff was seen and three dates have been provided. Five staff have done food hygiene training and five are booked on to Food Hygiene training for 13 March 2005. Maintenance records were up to date demonstrating that the home is well maintained and risk minimised accordingly. Fire drills are held regularly and are evidenced well. All windows are restricted and risk assessments to support the security of the building and fire risk are in place as are contingency plans in the event of an emergency. Contractors servicing the fire alarm system in November 2005 have recommended that the system is upgraded. Accidents have reduced in number but are being analysed. Those accidents, which have happened, are largely minor and risk assessments are in place to prevent the risk of reoccurrence. There have been no new staff since the last inspection to induct and newly introduced LDAFF induction has therefore not yet been piloted. The Inspector suggested conducting the pilot with 2 current but unqualified staff. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 23 Data sheets have been obtained for hazardous chemicals but the information has not been used as COSHH assessments are not in place. The Manager is aware of this. 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X 3 X 1 X X 2 X 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 Requirement The service user guide must be revised so as to include: Service users views of the home. When complete all service users and the Commission for Social Care Inspection must be supplied with a copy Requirement first made December 2002. Not Met at Feb 06. The Manager must ensure that all of service users needs / risks are assessed and are addressed in plans of care (including nutritional need, tissue viability) Timescale for action 31/05/06 2 YA2 15 31/03/06 3. YA2 15 New Requirement at Feb 06. Multidisciplinary reviews 31/03/06 of care must take place for all residents every six DS0000024960.V281832.R01.S.doc Version 5.1 Page 26 10 Chapel Street months. Dates for reviews for all residents must be set by the date given. A protocol for the management of six monthly review meetings must be agreed and recorded. Requirements first made January 2004. Service users specific medical diagnoses must be included in assessments of need with a plan of care to support the identified need. 4 YA6 15 31/03/06 5. YA6 15 Requirement first made March 2005. A system to monitor care 31/03/06 plans must be implemented. New requirement at July 05 The formats of the service user plans must be reviewed so as to enhance understanding of the individual and to make the process of agreement between the home and the service user more transparent by asking the service user /representative /advocate to sign the plan. Requirement first made and not met since December 2002. 6. YA6 15 31/05/06 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 27 7. YA6 13(2) Care plans must include all aspects of prescribed medication. New requirement at July 2005 Not Assessed at February 2006. In the event of the review of a care plan showing that the care plan is not effectively meeting its goal, the care plan must be modified. Requirement first made March 2004. 31/05/05 8. YA6 15 31/03/06 9. YA6 15 Not Met e.g. weights at Feb 06 Care plan must be drawn 31/05/06 up with evidenced involvement of service user, family, advocate etc – at Feb 06 one relative signed. Care plans must be in a format that the resident understands – Not Met Requirement first made 31.1.05 and not met since 31.3.05 The home must document if and when the service user make a decision. Requirement first made December 2002. Part met at Feb 06 – decisions recorded in service user meetings but not in individual 10. YA7 12 31/03/06 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 28 11 YA7 12 care records. Evidence that documented decisions have not been acted upon. Systems must be in place to ensure that requests / decisions made by service users in service user meetings are followed through and acted upon. Any restrictions which prevent this must be documented. New Requirement at Feb 06 The management must develop the formats of all their policies and procedures so that they are accessible and understandable by the service user group. 31/03/06 12. YA8 12 31/05/06 13. YA14 15 12(3) Requirement first made and not met since December 2002. 30/09/06 The manager must ensure that residents are meaningfully involved where possible in choosing and planning their annual holiday and that this is evidenced. How residents are supported to make choices must be included in each resident’s plan of care. Requirement first made 1st March 2005. Next Holiday Not Assessed 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 29 14 YA15 12 To establish format for recording contact with family and friends. Requirement first made 31.1.05 and not met since 31.3.05 Not assessed at Feb 06 The menu must offer daily choices to meet residents likes and dislikes, daily preferences and needs as determined by the care plan. Decision making processes for residents who are non-vocal must be recorded within individuals care plans. Not Assessed at Feb 06 Residents’ weights must be taken and recorded regularly and measured against Body Mass Index with any required action being care planned and monitored. At August 05 one service users weights not being taken as no access to appropriate scales. No change at Feb 06. 31/03/06 15. YA17 17(2),Sch4 (13) 31/03/06 16 YA17 Sch3, 3 M,Sch4,13 31/03/06 17 YA19 13(1)(b) Requirement first made 31.1.05 and not met since 31.3.05 Resident B must be 31/03/06 offered the opportunity to have his ears syringed as recommended by the DS0000024960.V281832.R01.S.doc Version 5.1 Page 30 10 Chapel Street nurse in September 2004. Requirement first made 1st March 2005 and not met at Feb 06 The option of routine hearing tests must be provided for all residents. Requirement first made January 2004 and not met at Feb 06 Service users dental appointments / dental treatment / dental advice must be evidenced. New Requirement at Feb 06 The manager must ensure: Only the staff member who administers the medication must sign for its administration. Requirements first made 1st March 2005. Not Assessed at Feb 06 A risk assessment and safe procedure must be written and made familiar to all staff about the administration of medication covertly to ensure the safety of all residents and staff. Requirement first made January 2004 and not met since 29.2.04 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 31 18. YA19 13(b) 13(5) 31/05/06 19 YA19 13 31/03/06 20. YA20 13(2) 07/02/06 21. YA20 13(2)(4) 28/02/06 22 YA21 12, 15 Not met at Feb 06 Each resident’s wishes concerning terminal care and death must be sensitively discussed with the resident or their representative where appropriate and recorded. At July 05 – parents of one service user approached Requirement first made March 2004 Not Assessed at Feb 06 Copies of the complaints and confidentiality policies must be provided to residents, relatives and other stakeholders. Requirement first made March 2004. Not Assessed at Feb 06 All staff must be provided with disability and race equality training. Requirement first made January 2004. 31/05/06 23 YA22 22 31/05/06 24 YA35 18(1)(c) 23(4) 31/05/06 25. YA23 17(1)(a) 13(6 & 7) 31/03/06 All restraint techniques must be agreed in a multi disciplinary forum, including the resident where possible. (At June 05 discussed in review for one service user – minutes not available at time of DS0000024960.V281832.R01.S.doc Version 5.1 Page 32 10 Chapel Street inspection). Not included in minutes at Feb 06. Verbal confirmation to the Manager that the homes physical intervention policy complies with the Department of Health Guidelines and the British Institute for Learning Disabilities must be requested in writing, and provided to the Commission for Social Care Inspection.(At Feb 06 letter suggested from trainer as evidence) Requirement first made March 2004 The wording in Restraint guidance in respect of a named service user which states ‘hold wrists firmly’ must be reviewed. New Requirement at Feb 06. The manager must ensure that there is a planned maintenance and renewal programme for the fabric and decoration of the premises, with records kept. The manager must include the replacement of the damaged tiles in the ground floor bathroom in a planned programme of maintenance and 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 33 26 YA23 13(6) 31/03/06 27 YA24 23(2)(b) 31/05/06 renewal and must inform the Commission for Social Care Inspection of a planned date for their replacement. Requirement first made 1st March 2005 28. YA26 16 23 Not Met at Feb 06 31/03/06 The registered provider must offer the service user the choice of having the access to the bedroom furniture prescribed within the National Minimum Standards. These items must be provided in accordance with service users wishes and as identified within risk assessments. If it is the service user’s express wish not to have certain items provided then this should be fully documented and kept under review. Records not available at Inspection Feb 06 – not evidenced. The Manager must 31/05/06 ensure that a detailed Infection Control Policy and procedure is available to guide staff in all aspects of infection control. New Requirement at Feb 06. 29 YA30 13(3) 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 34 30 YA32 18 The Manager must ensure that steps are taken to sufficiently reduce any risk posed by staff who are under 21 years old taking responsibility for service users. (Staff under 21 must not be in charge of service suers) New Requirement at Feb 06. Staffing levels must be kept under review. Requirement first made January 2004. Not Assessed at Feb 06 A risk assessment for the recruitment of SN without the necessary checks must be completed for SN. A medical questionnaire must be obtained in respect of SN. The Commission for Social Care Inspection must be informed about the outcome of the checks when received. Requirements first made 1st March 2005 and not met since 18.3.05 without delay. Not Assessed at Feb 06 28/02/06 31. YA33 18(1)(a) 31/03/06 32. YA34 19 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 35 33 YA34 YA31 17(2) Staff members must sign 07/02/06 Job descriptions held on staff files. Evidence of sending for Criminal Bureau checks prior to their return must be held on the premises. A copy of a birth certificate, passport, qualifications and proof of identity must be held on the premises for all staff as per Schedule 2 and 4. (Agreed can be held at Head Office if made available for inspection – ID not fully in place) Requirements first made January 2004 and not fully met since 31.3.04 Not Assessed at Feb 06 Newly appointed staff must not take up post prior to the receipt of an appropriate Criminal Record Check or without consultation with the Commission for Social Care Inspection . Requirement first made March 2004. Not Assessed (No New staff at Aug 05) Not Assessed at Feb 06 34. YA34 19 07/02/06 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 36 35. YA34 19 The Manager must review dependency levels of residents and associated care hours required / provided. Requirement made 31.1.05 Not Assessed at Feb 06 The provider must ensure that a decision is made in respect of how the home is to meet the Standard for the provision of Induction training to the required Standard. Requirement first made 1st March 2005 and not met at Feb 06 All staff must be provided with training in Autism Awareness. This must be booked by the date given. All staff must receive a personal copy of the home’s grievance and disciplinary policy and must sign to acknowledge receipt. Requirement first made January 2004. 31/05/06 36. YA35 18(1)(c) 28/02/06 37 YA35 18 31/03/06 38. YA36 18(2) 17(2) 31/03/06 39. YA39 24 Not Assessed at Feb 06 The registered Manager 31/05/06 must develop an annual development plan for the home based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service DS0000024960.V281832.R01.S.doc Version 5.1 Page 37 10 Chapel Street users. Requirement first made December 2002. 40. YA39 24 Not met at Feb 06 Systems must be in place to ensure quality monitoring. Requirement first made March 2004. At Feb 06 tool purchased but not used. Behaviour management plans must be reviewed in light of any advice given (by psychologist) At June 05 completed and sent to psychologist – not completed at Feb 06 (being typed up by Psyhology) – without delay. The homes challenging behaviour policy must be implemented in the event of employed restraint e.g. notification to Senior Manager and Social Worker. This policy must be amended to include notification to the Commission for Social Care Inspection. The Manager must ensure that the homes policy and training complies with Department of Health Guidelines and the Code of Practice published by 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 38 31/05/06 41. YA40 YA23 YA20 YA6 13(7) 31/05/06 the British Institute of Learning Disabilities. (Confirm in writing to CSCI) 42. YA41 15 Daily written shift records must reflect care plan goals. All entries must be service user focussed. Requirement first made 31.1.05 Not Met at Feb 06 The Manager must ensure that the Commission for Social Care Inspection is informed of all incidents that affect the welfare of residents. Requirement first made January 2004. No Incidents Next incident and ongoing Written guidance must be provided in respect of the criteria for notification to the Commission for Social Care Inspection of incidents affecting the welfare of residents. Requirement made 31.1.05 Not Assessed at Feb 06 The Manager must ensure that full COSHH assessments are drawn up from data sheets available for all Hazardous substances used and stored in the DS0000024960.V281832.R01.S.doc 31/03/06 43 YA42 37 07/02/06 44. YA42 37 35 28/02/06 45 YA42 13(4) 31/03/06 10 Chapel Street Version 5.1 Page 39 home. New Requirement at Feb 06 The Manager must seek and act upon the advice of the West Midlands Fire Service in respect of a contractors recent recommendation to upgrade the fire alarm system. Advice and any proposed action must be communicated in writing to CSCI by the date given. New Requirement at Feb 06 The Manager must confirm in writing to the Commission for Social Care Inspection that insurance cover meets all the requirements as listed in Standard 43.5 Requirement first made March 2004. Not Assessed at Feb 06 46 YA42 13(4) 23 31/03/06 47. YA43 25(2)(c)(e) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 10 Chapel Street DS0000024960.V281832.R01.S.doc Version 5.1 Page 40 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 10 Chapel Street DS0000024960.V281832.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. 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