CARE HOME ADULTS 18-65
118-120 Dudley Street West Bromwich West Midlands B70 9AJ Lead Inspector
Mrs Lesley Webb Key Unannounced Inspection 13th January 2007 09:30 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 118-120 Dudley Street Address West Bromwich West Midlands B70 9AJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 580 2573 0121 525 6257 Lonsdale (Midlands) Limited Marie Grogan Care Home 8 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (5), Learning disability over 65 years of places of age (2), Physical disability (8) 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 5 LD, 2 LD(E),1 DE(E) and up to 8 PD. Date of last inspection 29th December 2005 Brief Description of the Service: 118-120 Dudley Street is an 8-bedded nursing home for older adults with learning and physical disabilities. The home is situated close to local shops and amenities, is near to West Bromwich town centre, and is accessible by public transport. The service offers one shared and six single occupancy rooms, a communal lounge and dining area and assisted bathing facilities. Bedrooms are not en-suite. There is a domestic style laundry and kitchen, and a garden/patio area to the rear. A lift services the first floor. A range of services are available including assistance to access healthcare facilities, various in -house and external recreational pursuits, and community inclusion. The home has its own transport. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector with the home being given no prior notice. During the visit time was spent formally interviewing staff, examining records and observing care practices before giving feedback about the inspection to the registered manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals care provided at the home. For example the people chosen have differing communication and care needs, consist of male and female and have various cultural heritage. A relative of a service user was present during the inspection. Compliments were made regarding the home including “first class home, its brilliant”. When asked what makes it a good home the relative replied, “the staff, nothing is too much trouble, it feels like a family”. The home is registered to provide nursing care for adults with learning and physical disabilities, and other complex needs. Fees charged for living at the home range from £1131.59 to £1806.24. The service users present during this visit stated or indicated their satisfaction about the level of care and support they receive at the home. Formal interviews were not appropriate. However informal discussion and conversations about daily life were appropriate, and some of the occupants of the home were willing to participate. The inspection was conducted with the full co-operation of the registered manager and staff. The discussions and atmosphere throughout the inspection were positive and constructive. What the service does well:
Through observations of care practices, interviews with staff and a review of documentation it can be confirmed that as in previous inspections, the home generally is meeting the assessed needs of service users accommodated there. 118-120 Dudley Street offers a specialised service, including that of nursing to people (including some younger adults and older persons) with learning and physical disabilities, and other needs Generally individuals are involved in decisions about their lives, and where possible play an active role in planning the care and support they receive. Care planning is very good, ensuring staff have the right information in order to meet peoples needs. All staff that were interviewed demonstrated knowledge and understanding of care plans and their importance. For example one person explained, “they are important because from these we know peoples disabilities, their needs, daily living, what they can and can’t do and what we will have to do to help them, so we can know really well about the clients”.
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 6 Staff have good understanding of the communication needs of service users and their responsibilities to support people to be able to make decisions and choices. As one member of staff said, “from time people wake up we offer choices, what clothes they want, if they prefer having a wash or bathing, show different items at breakfast, what programmes on television. When shopping for toiletries what brands they want. For everything we ask for their choice, when shopping we always take with us so they can choose, we buy what they want what they like”. The atmosphere within the home is very relaxed and welcoming, with service users supported to maintain contact with family and friends as per their wishes. During the inspection a relative of a service user was observed visiting. Staff made the person very welcome, offered a drink and chatting in a very friendly manor. The relative confirmed this as normal practice of the home. All staff that were interviewed demonstrated understanding of supporting service users to maintain relationships. Responses included, “we involve in group activities, such as a game of cards, help them to phone families, arrange visits to families. Its important families are happy with the care their relatives receive”. Mealtimes are flexible. Service users are given a choice as to where to sit and eat, are not hurried and staff are available for assistance when necessary. The inspector indirectly observed service users at mealtime and found that staff sat and ate with service user, that everyone appeared very relaxed and happy, with service users laughing and interacting with staff. As in previous inspections staff have excellent knowledge of the personal care needs of service users and observation of practices confirm the principles of respect, dignity and privacy are put into practice. Staff were observed knocking on doors before entering toilets, bathrooms and bedrooms and talking to people in a friendly yet respectful way. Procedures and practices with the home in relation to medicines and controlled drugs were found to be good with no requirements identified. Medication in the custody of the home is handled according to the requirements of legislation and records are available, of medicines received, administered and leaving the home. Staff have good understanding of supporting service users to raise issues or complaint. As one person explained, “We do talk time every month which is a series of questions such as what they would like to change or what they are unhappy about, its quiet hard with communication barriers, but have a responsibility to build relationships so know they can come and talk to us if need to” and another “we encourage them to tell us any problems, if they don’t want to tell us we try to get them to talk to someone else. We also report to the manager”. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 7 The home continues to offer a good standard of furnishings and fittings and is well decorated. Bedrooms are decorated and furnished to a high standard and reflect individuals tastes and preferences. Supervision and support offered to staff is good. Staff that were interviewed confirmed they receive appropriate support with comments including, “ we get support from other staff members, we work as a team, even the manager and qualified staff. We also get support from clients, its really good team work, I have just joined but I am really satisfied, everyone respects each other, works as a team”. Discussions and observations confirm that the home is being managed appropriately. The manager is aware of areas that require improving, with evidence that action is taken within appropriate timescales to address deficits. The Registered Manager has appropriate qualifications and experience for the post, and undertakes periodic training and development to maintain her knowledge and skills. What has improved since the last inspection? What they could do better:
Priority must be given to ensuring all staff employed at the home participate in a fire evacuation at least every 6 months and that they also receive fire training at least annually. Due to all service users who currently reside at the home requiring high levels of assistance and support, staff are required to be fully trained and competent in relation to actions to be taken in the event of a fire, otherwise service users have the potential to be placed at risk. Work must also be undertaken to ensure service users are given the opportunity to access external activities on a regular basis as per their assessed needs. Currently these are restricted due to staffing levels and budget allocation. Finally some records require developing in order that the home can demonstrate staff receive training in sufficient numbers and in all required areas appropriate to their roles and that evidence that any concerns or requests raised by service users are investigated. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 9 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 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to demonstrate its capacity to meet the assessed needs of service users. Specialised services offered reflect current good practice and clinical guidance. EVIDENCE: Through observations of care practices, interviews with staff and a review of documentation it can be confirmed that as in previous inspections, the home generally is meeting the assessed needs of service users accommodated there. 118-120 Dudley Street offers a specialised service, including that of nursing to people (including some younger adults and older persons) with learning and physical disabilities, and other needs. The homes certificate of registration accurately reflects the primary care needs of those accommodated. Specialised services offered reflect current good practice and clinical guidance. All service user files sampled contained the appropriate pre-admissions documentation, including assessments of need completed by the relevant placing authority. When discussing admission processes the registered manager demonstrated understanding of her responsibilities in relation to assessing prospective service users and compatibility of those already living at the home.
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 11 Information supplied to the Commission for Social Care Inspection (CSCI) prior to this unannounced visit states that since the last inspection the statement of purpose has been updated and is now available in pictorial format. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally individuals are involved in decisions about their lives, and where possible play an active role in planning the care and support they receive. Care planning is very good, ensuring staff have the right information in order to meet peoples needs. EVIDENCE: Care plans are good; contain specific aims and goals including a break down of tasks in order that staff have sufficient information in order to meet the needs of service users. Plans in place include those for communication, personal care, community access, nutrition, health and personal care. In addition to these specific plans have been implemented for additional needs for named service users such as diabetes, epilepsy, religion and behaviours. All files sampled contained evidence that plans are reviewed on a monthly basis by staff at the home and that risk assessments are in place that support the contents of each plan of care. All staff that were interviewed demonstrated knowledge and understanding of care plans and their importance. For example one person explained, “they are important because from these we
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 13 know peoples disabilities, their needs, daily living, what they can and can’t do and what we will have to do to help them, so we can know really well about the clients”. A requirement identified in the previous inspection to implement person centred planning is part met. Practices observed and discussions with staff demonstrate that the principles of person centred planning are put into practice within the home but that documentation supporting this is still required to be put into place for all service users. It is recommended that further guidance regarding person centred planning be given to some staff. When interviewing staff about this approach to care planning some were not able to explain in sufficient detail what is was. For example one person said, “I don’t know too much about that, think its personal thinking about self, what they want in a particular way”. Others however demonstrated very good understanding in this area, for example saying, “where the person is involved in their own planning of their life so they are in control, having the chance to chose even though they have a learning disability, its equal, this can get missed, just because they have a learning disability doesn’t mean they cant be in charge of their life”. Systems are in place to support people to make decisions but further work is required to ensure documentation reflects choices made and when requests by service users are not implemented. Meetings with service users take place in the form of “talk time” these are one to one sessions where questions set on the agenda include ‘what would you like to do’, ‘where would you like to go’, ‘what are your hopes and dreams’. The outcome of these meetings is recorded but not of actual action taken to address requests or when these are not complied with. The registered manager agreed that improvements to the recording of these meetings should take place. Staff have good understanding of the communication needs of service users and their responsibilities to support people to be able to make decisions and choices. As one member of staff said, “from time people wake up we offer choices, what clothes they want, if they prefer having a wash or bathing, show different items at breakfast, what programmes on television. When shopping for toiletries what brands they want. For everything we ask for their choice, when shopping we always take with us so they can choose, we buy what they want what they like”. Generally risk management is good, ensuring those receiving a service are protected but not restricted. As already mentioned assessments are completed that work in conjunction with care plans for all identified needs. When examining risk assessments the inspector found that several new additions have been added to service user files for the company vehicle, bedrails and the kitchen. All of these are generic assessments and not based on each persons individual needs and capabilities. The inspector recommends that either new ones be implemented or these moved to the general health and safety risk assessment folder. As with care planning all staff spoken to demonstrated understanding of risk management. For example one person explained, “ Even though people have difficulties they are still independent, have risk
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 14 assessments but they do as much as can for selves. to reduce risk so clients can still do things”. Assessments tell us how 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 15 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally people who use this service are able to make choices about their life style, and supported to develop their life skills based on their individual needs and capabilities. In some instances staffing levels impact on social, educational, cultural and recreational activities, resulting in some needs not currently being met. The atmosphere within the home is very relaxed and welcoming, with service users supported to maintain contact with family and friends as per their wishes. EVIDENCE: Examination of records and discussions with staff and the registered manager confirm that external activities do take place but that these are limited due to all service users requiring at least one to one when out in the community. The records of three service users were examined for a one month period, these detail four visits to family for one service user, one visit to the cinema for the second service user and one visit to the shops for the third. When discussing
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 16 the lack of external activities with the manager the inspector was informed that as well as additional staffing the cost of staffs entrance fees needed to be considered. When asked for the total budget allocated to the home for activities the registered manager was unable to provide this stating that £350 is given to the home each week and from this provisions, cleaning equipment and activities including staffs expenses was funded. The registered manager acknowledges that it is the homes responsibility to ensure service users lead fulfilling lives based on their assessed needs, confirming that she would like to offer more choice, but is restricted due to staffing requirements and finances. When assessing this situation the inspector was concerned to find a hydrotherapy assessment that states ‘suitable leisure facilities should be found by the home’ with no evidence of this occurring. The registered manager confirmed this is being looked into but that funds for additional staffing (two members of staff would need to accompany the service user) are required. It was also noted that a cookery lesson for another service user was cancelled due to ‘support worker on external errands as driver’. Activity records describe a variety of in-house events including armchair aerobics, watching television, colouring, music sessions, bingo, playing cards (this was also observed to take place during the inspection) and board games. Some discrepancies were found in relation to activity plans and actual events taking place however the registered manager explained that new activity diaries are being implemented for each person. She explained that each person would have individual diary that is personalised with photographs and pictures. Staff will then record what they have done both in-house and external. In addition to this the registered manager indicated to an activity timetable that has been produced in picture format that details a variety of events. She confirmed that each person would have his or her own individualised timetable. As mentioned previously in this report service users wishes in relation to activities and other events are obtained but improvements to records relating to these is required. The home must be able to evidence requests made by service users that have been actioned and record where these are not implemented and why. As in previous inspection the atmosphere within the home is very relaxed and welcoming with an abundance of evidence that indicates relatives and friends of service users are embraced by the home, with service users supported to maintain contact as per their wishes. Dudley Street operates an open visiting policy, and welcomes relatives and friends of service users at any reasonable time. There is no restriction with regard to visiting times. The home actively supports maintaining contact with friends and relatives. The Registered Manager keeps relatives regularly updated with any changes/incidents. Limited communal space is available where visitors can meet their relatives in privacy, but service users can access their own rooms with relatives if desired. During the inspection a relative of a service user was observed visiting. Staff made the person very welcome, offered a drink and chatting in a very friendly manor. The relative confirmed this as normal practice of the home. All staff that were interviewed demonstrated understanding of supporting service users to maintain relationships. Responses included, “we involve in group activities,
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 17 such as a game of cards, help them to phone families, arrange visits to families. Its important families are happy with the care their relatives receive”. Service users at Dudley Street continue to be offered a variety of meals based on their likes/dislikes. Regular meals, snacks and hot/cold drinks are available. Meal planning and mealtimes are flexible, and can be changed, as needed/requested. Service users are given a choice as to where to sit and eat, are not hurried and staff are available for assistance when necessary. The inspector indirectly observed service users at mealtime and found that staff sat and ate with service user, that everyone appeared very relaxed and happy, with service users laughing and interacting with staff. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. As in previous inspections the health and personal care that people receive is based on the individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: As in previous inspections staff have excellent knowledge of the personal care needs of service users and observation of practices confirm the principles of respect, dignity and privacy are put into practice. Staff were observed knocking on doors before entering toilets, bathrooms and bedrooms and talking to people in a friendly yet respectful way. Service users have access to a telephone, are spoken to using a preferred term of address, (which is documented) and arrangements are in place to ensure personal clothing and laundry is returned to its owner. Also as in previous inspections health care management and documentation is excellent. Information supplied to CSCI prior to the inspection states that support services such as general practitioners; district nurses, occupational therapists and dieticians are obtained via a referral system. Also that six monthly dentist reviews in place, annual appointments with opticians occur,
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 19 that chiropody treatment takes place every three months and reviews with the consultant psychiatrist are arranged every six months. Records maintained on the three service users files sampled confirm this information to be true. The home should also be commended for other health care documentation in place. These include specialist learning disability care plans, person centred health action plans and records relating to specific health needs such as diabetes and epilepsy. Procedures and practices with the home in relation to medicines and controlled drugs were found to be good with no requirements identified. There are no residents who self administered at the time of inspection and specimen signatures were available of qualified staff who administer medication to service users. Since the last inspection staff signatures for the homes updated medication policy have been obtained as an acknowledgement of its content/existence (meeting a previous requirement). Medication in the custody of the home is handled according to the requirements of legislation and records are available, of medicines received, administered and leaving the home. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, have access to a robust, effective complaints procedure, are protected from abuse and have their rights protected. EVIDENCE: Staff have good understanding of supporting service users to raise issues or complaint. As one person explained, “We do talk time every month which is a series of questions such as what they would like to change or what they are unhappy about, its quiet hard with communication barriers, but have a responsibility to build relationships so know they can come and talk to us if need to” and another “we encourage them to tell us any problems, if they don’t want to tell us we try to get them to talk to someone else. We also report to the manager”. Complaints policies and procedures are appropriate, including being provided in alternative formats. The complaints folder is displayed at the entrance of home, with none recorded for several years. When examining the complaints procedure the inspector noted that a laminated version of this states that if a complainant is not satisfied with the homes investigation and outcome they can refer to CSCI (a more in-depth version states complainants have the right to refer to CSCI at any stage – as per the National Minimum Standards). When exploring why the home does not receive any complaints the inspector was informed by staff and the registered manager that service users have the
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 21 opportunity to raise issues in monthly meetings (known as talk time) and this allows the home to address issues before they escalate to formal complaints. When examining the records of these meetings the inspector instructed that further work is undertaken by the home to evidence that issues raised are investigated including maintaining a record of outcomes. For example one service user raised concerns that they are unhappy with a ‘noisy’ service user but no evidence could be found that this had been investigated or that the service user was happy with the outcome. Improvements in this area will enhance systems already in place. A relative of a service user visiting the home at the time of the inspection confirmed that management and staff are open to criticism and that they are not victimised for raising concerns on behalf of service users. The inspector examined a sample of protection policies and procedures (physical intervention, adult protection and whistle blowing), finding all to be appropriate. Also records and systems for the management of service users finances are good, offering protection to those living at the home. Individual allowance sheets are maintained along with receipts for all transactions. In addition to this safe checks are undertaken twice a day. As with complaints staff have good understanding of protecting service users from abuse. When asked how they can protect service users responses include, “if I thought someone was being abused in any way I would report it to the person in charge of the shift and document on paper. If it was the person in charge I would go higher”. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who reside there to live in a safe, well-maintained and comfortable environment. EVIDENCE: At this unannounced inspection Dudley Street was again found to be comfortable, well maintained and clean. There were no offensive odours and the premises offer adequate light and ventilation. The home continues to offer a good standard of furnishings and fittings and is well decorated. A maintenance and renewal programme has been formulated, although regular environment audits are being conducted. The premises are in keeping with the local community, and offers access to local amenities and transport. Since the last inspection an extension to the property has been completed providing two refurbished bedrooms with en-suite shower facilities. In addition, two existing bedrooms have been made larger. The office has been transferred to the ground floor with the registered manager stating that the room previously used
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 23 for this purpose going to be allocated as a staff room. She also informed the inspector that a room that used to be a bedroom is being considered to use as a sensory/games room. The inspector recommends this consideration be implemented. Specialised equipment is in place as required to meet service users needs. Bedrooms are decorated and furnished to a high standard and reflect individuals tastes and preferences. Laundry facilities are appropriate and are sited in a separate area designated for the purpose. Laundry products (i.e. washing powder and fabric conditioner) are kept locked away and the room is fitted with a lock to be used when unattended. Equipment provided ensures foul laundry is washed at appropriate temperatures, and the washing machine has a sluicing facility. Laundry facilities do not intrude on resident’s routines, and walls and floors are readily cleanable. The homes Infection Control policy states that laundry to be washed is not to be carried through the lounge, and must be transported in appropriate containers or disposable bags. `Designated` baskets are identified for sorting clean and dirty laundry. It was noted when inspecting the laundry that mops are not being stored appropriately, despite facilities being in place for this. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels have the potential to impact on the quality of service people receive living at the home. Improvements to training systems are required to ensure the staff team are appropriately qualified. Recruitment procedures are robust and protect those living at the home. Service users benefit from well supported and supervised staff. EVIDENCE: Observations of interactions between service users and staff, discussions with service users and staff confirm that excellent relationships have been developed. The home operates at staffing levels of one qualified nurse and three support workers during wakeful hours, and one qualified nurse and one support worker during the nighttime. At the previous inspection the registered manager was advised of the need to monitor and adjust staffing levels to ensure the needs of service users are being met and where necessary contact the appropriate health professional to conduct a reassessment. Evidence gained within this inspection (see standards 12 to 14 of this report) indicates that the current
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 25 staffing levels are not meeting the needs of service users in relation to community access and external activities. The registered manager was instructed that action must be taken to address this, including the reassessment of service users residing at the home. Staffing levels and their impact on activities was reinforced on one of the two relatives comment cards received by CSCI states ‘the level of staff available at the home restricts the clients being taken to the theatre and other outings, but everything else is first class’. In addition to this the home does not employ any domestic, kitchen or laundry staff with care staff undertaking all of these duties in addition to that of direct care. This also has the potential to impact on external activities. Staff meetings occur monthly (it was noted that non took place between March and August 2006). Records of these appear appropriate but would benefit from detailing who is responsible for agreed actions and when. It was also noted that only one managers meeting has taken place in a considerable time (November 06). Recruitment procedures and documentation are good, ensuring the protection of service users. This would be further enhanced if service users were supported to be involved in this process. All of the staff files sampled contained the required documentation as listed in the Care Homes Regulations 2001. The inspector had difficulty assessing if staff are trained in sufficient numbers as the training and development plan and training matrix had not been updated. There was a staff list on the notice board in the office detailing courses staff need to attend but this did not detail if they currently hold an up to date certificate in the various fields or indicate when training would be achieved. In order to ascertain training that staff have received the inspector would have needed to view all employees certificates. Of the four staff files sampled two contained a certificate for non-violent crisis intervention, two epilepsy, four fire, three health and safety, three abuse, one fire equipment, two infection control, four manual handling, three first aid, two equal opportunities, three food hygiene, one medication awareness, one dementia awareness, two stress awareness and one learning disability awareness. It was also noted that some of the certificates were out of date. It was pleasing to find that the number of NVQ level 2 trained staff is now meeting the proposed targets set by the Commission for Social Care Inspection and `Skills for Care`, meeting a recommendation identified in the previous inspection. All but one member of care staff is now enrolled to undertake this qualification. Supervision and support offered to staff is good, with all staff files sampled containing evidence that they receive formal one to one supervision on a regular basis, in addition to an annual appraisal. Staff that were interviewed confirmed they receive appropriate support with comments including, “ we get
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 26 support from other staff members, we work as a team, even the manager and qualified staff. We also get support from clients, its really good team work, I have just joined but I am really satisfied, everyone respects each other, works as a team”. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect, with effective quality assurance systems that allow the home to measure if it is meeting its aims and objectives. Health and safety is appropriately managed, apart from the lack of fire training for staff, this has the potential to place people living at the home at risk. EVIDENCE: Discussions and observations confirm that the home is being managed appropriately. The manager is aware of areas that require improving, with evidence that action is taken within appropriate timescales to address deficits. The Registered Manager has appropriate qualifications and experience for the post, and undertakes periodic training and development to maintain her
118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 28 knowledge and skills. She is a Registered Nurse (Learning Disability), is a Learning Disability Awards Framework assessor, and is nearing completion of the NVQ level 4/Registered Managers Award qualification. Generally there are good quality assurance systems in place. An annual development plan for January to December 2006 was seen by the inspection, with the registered manager already aware of the need to review this document. The development plan details aims in relation to choice of home, health and personal care, social contacts and activities, complaints, environment, staffing and finance. The inspector recommends that this should be developed to evidence what has been achieved, what not and why so as to evidence continuous improvement and to demonstrate the document is used as a working tool. In November 2006 a quality assurance audit was completed by a person independent to the home. The audit was based on outcomes for service users such as ‘service users are able to decide where they want to live and chose the home that will meet their needs and expectations’ and ‘service users are supported to take decisions about their own lives’. The inspector was pleased to find that many areas identified in the CSCI inspection have already been identified within this audit such as evidencing service user involvement in recruitment, increasing activities and service user meetings. It is recommended that the home action all areas of the annual audit to ensure continued quality service provision. Generally heath and safety is appropriately managed apart from fire training for staff. Information supplied to CSCI prior to the inspection details sixteen staff employed at the home. Records viewed by the inspector show only twelve of these have undertaken a fire evacuation in the last twelve months and only nine fire training. The registered manager was instructed that action must be taken to address this as a matter of priority. All other records relating to health and safety appear appropriate and evidence the required checks and maintenance in relation to gas, electric, water and equipment. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 3 X 3 X X 2 X 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 01/03/07 2 YA7 The home should progress with the implementation of a system of Person Centred Planning – part met. Requirement originally made 2005. 12(2) That records are maintained to 16(2)(m)(n) evidence action taken to address issues/requests made by service users. That records are maintained of reasons why requests made by service users are not complied with. 16(2)(m)(n) That service users be given the opportunities to access external activities on a regular basis. That an activity budget be allocated that ensures funds are available, in sufficient amounts for staff expenses, in order that service users can receive the required support to access community activities on a regular basis. That records are maintained that evidence any concerns raised by service users are investigated.
DS0000004771.V326105.R01.S.doc 01/03/07 3 YA13 01/04/07 4 YA22 22 01/03/07 118-120 Dudley Street Version 5.2 Page 31 5 YA33 14(2) 18(1)(a) That formal reassessments of needs be undertaken of all service users. That staffing levels be increased to allow for community access and external activities. That training and development documentation is maintained up to date. That staff received training in sufficient numbers and in all required areas appropriate to their role. That all staff participate in a fire evacuation at least every 6 months. That all staff undertake fire training at least annually. 01/04/07 6 YA35 18(1)(a) 01/04/07 7 YA42 23(2)(d)(e) 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard YA6 YA9 YA14 YA24 YA30 YA33 YA34 Good Practice Recommendations That staff receive guidance and advice regarding person centred planning. That generic risk assessments are not stored in service users personal files. That the home continues to introduce new activity systems. That a disused bedroom be converted to a sensory/games room. That mops are stored in line with infection control guidelines. That the minutes of staff meetings include who is responsible for agreed actions, what these will entail and when they will be achieved. That service users are involved in the recruitment and selection of staff.
DS0000004771.V326105.R01.S.doc Version 5.2 Page 32 118-120 Dudley Street 8 9 YA39 YA39 That the annual development plan be reviewed and include evidence of what has been achieved, what not and why. That action is taken to address all issues identified in the annual audit undertaken in November 2006. 118-120 Dudley Street DS0000004771.V326105.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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