CARE HOME ADULTS 18-65
Castle Lane, 126 126 Castle Lane Olton Solihull B92 8RW Lead Inspector
Joe OConnor Unannounced 16 August 2005 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 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 Stationary 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. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Castle Lane, 126 Address 126 Castle Lane Olton Solihull West Midlands B92 8RW 0121 743 1110 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Robinia Care West Midlands Ltd Miss Christine Higgins Care Home 3 Category(ies) of Younger Adults, Learning Disability [3] registration, with number of places Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Should the standard of the care within the home deteriorate due to the manager being responsible for two other homes, then an individual manager will be required. 2. Staff sleeping in facilities must be provided within 6 months of registration. 3. That Christine Beverley Higgins completes a recognised accredited training programme in physical intervention by 30th September 2005. Please note that condition 2 & 3 have been met, and will not appear in the next inspection report. Date of last inspection 15 February 2005 Brief Description of the Service: 126 Castle Lane is located along a quiet residential road in the Olton area of Solihull. The service is close to local bus routes for Solihull and Birmingham. It is within reasonable walking distance to local amenities. It is currently registered to provide accommodation and support for three adults with a learning disability. The current group of service users are three women. The premises consist of three single bedrooms one of which is located on the ground floor as part of a garage conversion and has a wash hand basin. There is a separate lounge and dining room with a fully equipped kitchen. On the first floor is a bathroom with a bath, shower cubicle, toilet and wash hand basin. There is also an office that is used as a sleep in room. There is a toilet on the ground floor. To the rear of the property is a large well maintained mainly lawned garden and there is limited roadside parking. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during the afternoon with the assistance of Margaret Wyre who is known as an Expert by Experience and her supporter Becky Ley from Sandwell People First Organisation. They spoke with two service users and one member of staff and had a look at one of the service users’ bedrooms. The Inspector spoke to one service user and a member of staff known as a team leader. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also sampled. A number of health and safety records were also examined. Observations of care practices were also undertaken. What the service does well:
Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as care home is not known. The expert by experience commented that she thought the women lived in a home that was clean, tidy and homely, and also felt positive that it was very much part of the local community. This was because apart from one of the neighbours one of the service users found them very friendly and was able to talk to them. She enjoyed her visit. Two service users who spoke with the expert by experience expressed their delight at the staff and their home saying how happy they were. The expert by experience and her supporter found the service users and staff to be welcoming and were offered drinks and biscuits. She also felt that it was nice there was a separate dining rooms from the lounge for extra room if the service users did not want to sit together. Two of the service users who spoke with the expert by experience stated they were able to choose what they wanted to eat and go out shopping for the food. One service user stated that she was able to choose her own clothes and the expert by experience thought it was good that both of the women spoken with were able have choices in their lives. There are meetings for the service users every week where they have the opportunity to raise any grumbles. The expert by experience was pleased to find that at least one of the service users has an active life during the day. One service user has a boyfriend who she is able to visit often and can invite him over for a meal. She also has a key to her front door and goes swimming. An examination of their care records found that the service users had been involved in activities such as the cinema, horse riding meals out and picnics at various parks. The two other service users prefer to stay in during the evenings but will sometimes go out together for a drink and meal. Service users are able to maintain contact with their families while one service user has regular support from an advocate. Two service users told the expert by experience that they are involved in the interview process of recruiting new staff and have the final word on who should
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 6 work with them. Both service users said they liked the staff and had their own key workers. Care records for the service users confirmed where service users had received treatment from a GP, optician, dentist and chiropodist. The service users also have access to specialist support from professionals such as a Consultant Psychiatrist and Psychologist. The management of medication was of a very good standard. What has improved since the last inspection? What they could do better:
The expert by experience commented that while it was good to see that one of the service users had a full active life, she was not so sure the other two had the same choices. This was confirmed when two of the service users stated there was only one member of staff on duty during the evening. And sometimes two of the service users are taken out at the same time limiting their opportunity of when not to go out. The staff rotas found that staffing levels were not being maintained during the day as well as the night. The
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 7 levels of staffing at night are still not sufficient in meeting the needs of service users and this remains an outstanding requirement from the previous inspection. An examination of one service users’ care plan found there had been a significant number of incidents involving aggressive behaviour towards other service users and staff, which is placing all, concerned at risk. One of the staff recruitment records examined did not have confirmation that the staff member concerned had a CRB check to confirm they were suitable to work with the service users. The expert by experience commented that she would like to see the service users becoming more involved in preparing their own meals and should be encouraged to be as independent as possible. The complaints procedure must be available in a large print format as the expert by experience commented that she had to have assistance from her supporter to read the writing which is very small. The expert by experience was concerned when one of the women introduced herself as a service user, and felt she should not be encouraged to give herself a label which the expert by experience feels very strongly about. 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. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 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 standard(s) 3 Service users needs are not met in full due to inappropriate levels of staffing during the evenings. EVIDENCE: Two service users spoke with satisfaction to the expert by experience about the care and support they received. Both expressed their delight at the staff and their home saying how happy they are here. The manager had addressed a number of requirements from the previous inspection. A sample of service users records indicated that the manager had introduced person centred plans including to provide more personalised information as to how the service was to meet the individual needs. There have been no admissions since the last inspection although there was written evidence to confirm that the manager had requested a review by social services for one service user with regard to changes in their behaviour and had enlisted the services of a clinical psychologist to assess the individual’s concerns. While there was evidence that certain aspects of the service users needs were being met, the current levels of staffing do not meet the needs of the current group of service users during the evening. Service users were dressed appropriately for their age and lifestyle. Observations at the time of this inspection indicated that the interaction between service users and staff was positive and friendly. When the expert by experienced arrived she was concerned that one of the women had introduced herself as a service user and this made her
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 10 uncomfortable and felt that the service user is a person and should not be encouraged to give herself labels. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 Care plans provide detailed information of service users needs. These will require some improvement to show how identified needs are to be addressed. Service users are encouraged to make decisions about their lives through the use of service users meetings and on a day to day basis with support from staff. Service users have risks assessments concerning limitations on their independence. EVIDENCE: During the visit the Expert by Experience asked one service user if she knew about her care plan but she did not appear to understand the question. A member of staff helped the service user to answer the question and said all three service users had a copy of their care plan in their bedrooms. The manager has worked with the service users service users to produce a care plan that is easy to understand. They all have a person centred plan and are worked on with the individual service user being the centre person. An examination of the care records found that while there were detailed care plans in place, the information did not fully highlight how the needs of service users are to be met and by whom. Each service user does have a person centred plan but it was noted that one did not provide specific information about service users likes, dislikes and how they were to be supported to arrange medical appointments. For example one did not say what kind of
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 12 music the service user liked listening to and who were her favourite performers. Another care plan did not set out how service users made choices with regard to getting dressed and when they wanted to get up and go to bed. One of the care plans seen had been reviewed but there was no evidence that the service user was involved neither was there any documented evidence to confirm what action was to be taken following the review. The expert by experience asked two service users who goes shopping for food. One said they and another service user go out shopping and that every evening they all sit down and make a shopping list for a weekly shop. The staff provide support for the service users to go and buy the food shopping on a Friday. One service user did say that she was able to change her mind throughout the week if she fancied something different, rather than what was planned. They buy extra different food in case anyone changes her mind. The expert by experience was pleased to hear that the service users could eat whatever they want and are involved in the planning of the meals and shopping. However, she was concerned that the service users do not cook or are supported to although the service users said they were happy for staff to make the meals. One service user said she liked getting involved in baking cakes and enjoys cleaning up afterwards. The service user said she is also able to make herself a drink whenever she would like one. Two service users told the expert by experience that they have their own bank accounts and the third is in the process of having one set up, but is finding it difficult possibly because the service user is without speech. The staff help support the service users budget their own money. One service user likes to spend her money on magazines. With two of the service users having bank accounts means that the manger had addressed this requirement from the previous inspection. One service user goes out on her own and she often goes to visit her boyfriend and enjoys going with him to Hednesford Race Course. The Expert by Experience was really pleased to see how happy and busy the service user is with her life. They are often out with each other doing different things. Another service user has friends at college but no one close enough outside college. Each service user has a risk assessment that covers areas such service users’ road safety and for managing any difficulties when service users became upset or angry. One risk assessment had guidance in place for one service user when she went out on her own and what action was to be taken if she got into difficulty. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16, 17 Service users have access to leisure activities but arrangements must be in place for them to go on holiday when they choose to. Service users maintain positive relationships with staff and with each other and are part of the local community. Service users are not subjected to any unnecessary restrictions subject to their individual risk assessments. Service users have access to nutritious meals with some improvements required in recording what service users have had to eat and drink. EVIDENCE: One service user attends a day service provided by the local authority while the others have attended courses at a local college. An examination of service users records found that service users also took part in other activities such as horse riding, cinema, swimming and walks to local parks and shopping. Service users records also referred to examples where they had completed tasks such as making a drink, laundry and ironing. Two service users told the expert by experience they go to college and horse riding. One service user stated she liked to go to a sensory centre weekly and really likes to spend time on her own listening to her music. Another service user goes to a day centre, which staff said she seems to enjoy. The expert by experience was concerned that
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 14 there was only one member of staff on duty during the evening and felt that because of this the service users did not have a choice of when to go out if they were with a member of staff who did not know the service users. An examination of the staff rotas for the previous four weeks confirmed the comments made by the expert by experience. She also commented that while it was pleasing to see one service user having a very active life it was not certain whether the other service users have the same choices. It was of concern to be informed by staff that the service users had a planned holiday cancelled due to a lack of funds. Staff commented that they were advised by the organisation to re-arrange the holiday during a low season period. One service user told the expert by experience that in the past she had good holidays together with the other service users and had previously been to Euro Disney. The expert by experience commented that she hoped the service users get the opportunity to go away this year. Service users routines were known and respected and service users daily records stated where service users had declined activities and had requested a lie in. The interaction between service users was positive and friendly and two service users expressed their delight to the expert by experience to the staff and how happy they were living in their accommodation. One service user told the expert by experience that every other week her boyfriend comes over for dinner and is welcome to visit at other times as well. The service user stated she is able to visit him whenever she likes and is able to go in and out of the house as often as she likes. She also has her own front door key. A member of staff stated that all three service users have lived together for five years and are really close friends and often look out for each other. One service user said she enjoyed living with the others and would not like to change it. Another service user stated that she had an advocate who visits every week and liked him because he was fun, which the expert by experience was really pleased for, as the service user does not have any family in her life. The expert by experience was pleased that the service users were really positive being friendly with the neighbours and felt where they were living was very much part of the local community. However, one service user did comment that the neighbours on one side were not very nice. Menus sampled found that that service users had access to nutritious meals and record was being maintained but it was noted there were gaps in the recording. The records refer clearly to what choices of drinks were available for supper. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18, 19, 20 Service users receive flexible care and support to meet their individual requirements. Service users healthcare is appropriately arranged by staff promoting and maintaining good health, with improvements in records required. Medication management was found to be of a good standard promoting the good health of service users. EVIDENCE: The service currently accommodates three women and there are female members of staff available during the day to assist with their personal care. An examination of service users records found that manual handling assessments were in place. There was evidence that service users were able to access local healthcare facilities such as the GP, Optician, Dentist, and Chiropodist. Service users also have access to specialist healthcare support provided by the Primary Care Learning Disability Trust such as Consultant Psychiatrist and Psychologist. The management of medication was found to be of a good standard. There were no gaps in recording on the Medicines Administration Records or MAR sheets. The manager had developed a medication procedure that was more localised although the organisation’s procedure was found to require a number of amendments including that any medication errors must be reported to the CSCI and that all staff will receive accredited training in the safe handling of medicines. There was documented evidence to confirm where service users had medication reviews and there were guidelines in place for the use of PRN
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 16 medication or ‘when required’ as it is known. There was also a risk assessment in place for one service user who was taking their own medication. Copies of prescriptions were attached to the Medicines Administration Records that was a requirement from the previous inspection. Service users have yearly healthcare checks but one service users’ record sampled lacked information with regard to most recent dental and optician checks. Service users’ weight was recorded every month. There was documented evidence to confirm where service users had not given their consent to medical treatment. Standard 21 was not assessed in depth but it was noted that one service user was being consulted by an advocate regarding her final wishes. However, another file examined found that one service users’ final wishes record was found to be incomplete. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 17 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 standard(s) 22, 23 Service users have access to a complaints procedure but improvements are required to ensure it is in a more accessible format. Service users welfare is protected with staff receiving training in the protection of vulnerable adults. EVIDENCE: The CSCI have not had any complaints since the last inspection but an examination of the complaints records found that two service users had made complaints where they felt staff were making them go out on activities when one or both service users wanted to remain at home. It was good to see that the manager had written to them in response to their complaint outlining what action she would be taking. This was a requirement from the previous inspection. One service user was asked by the expert by experience what would she do if she were unhappy about anything, but was unsure of the question. A member of staff supported the service user and said that book is filled in each day, which included any grumbles. A grumble is if the service users are unhappy with anything at all and the staff are to record it as a grumble. The manager regularly checks the grumbles and if they are serious these are investigated It was noted that there is a complaints procedure on display in the hallway produced by the organisation. This was found to combine the use of illustrations and the use of a photo of the service manager for the organisation. The expert by experience commented that while the pictures and words were good the writing and the pictures were too small and that the complaints policy should be available in large print for service users to be able to read. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 18 Staff training records showed that staff had completed training in the protection of vulnerable adults and physical intervention. An up to date copy of the Local Authority’s Multi Agency Guidelines published by Birmingham Social Care & Health was on display in the office. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 19 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 standard(s) 24, 26, 28, 29, 30 Service users live in premises that are maintained to an acceptable standard and provide a homely, clean safe environment. Service users bedrooms are decorated to their individual preferences and lifestyle. There is adequate shared space that is available and comfortable and offers privacy for service users. Access must be improved for service users with mobility difficulties from the lounge to the garden patio. EVIDENCE: The manager had addressed a number of requirements since the last inspection. First appropriate locks had been fitted to two service users’ bedrooms. The lounge had been re-decorated and new settees were in place in the lounge. One service user did show her bedroom and said this had been redecorated and that she had chosen the colour scheme herself. The bedroom was found to be very personalised although it was noted that the service user’s bed was up against an uncovered radiator making access to the temperature adjustment valve difficult to reach. The manager had taken action from the previous inspection for all of the service users bedroom doors to have suitable locks that guaranteed their privacy but could be accessible in emergency for staff. Consideration must be given for the radiator to be covered. While standing in the back garden it was noted that there was a long step down from
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 20 the patio door to the ground and as there is one service user with mobility difficulties and a grab rail must be fitted to assist with access to the garden. The expert by experience did comment that she thought the garden was nice and spacious and a service user said she like to enjoy a barbeque outside. The expert by experience also said that having a separate dining room from the lounge was nice as it provided the service users extra rooms downstairs if they did not want to sit together. It was good to see that the lounge had been redecorated since the last inspection and there was a new settee and armchairs which one service user commented were very nice. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, 36 Staffing levels do not provide service users with a continuity of care that meets their needs and is placing them and staff at risk. Service users are supported by staff that are competent and qualified to meet their needs. The organisation provides training to all staff employed to enhance their development. Staff recruitment records needed some improvement to ensure service users interests are protected. Staff are offered and provided training that enables staff to undertake their duties. Staff receive frequent supervision as part of their development and duties. EVIDENCE: Staff demonstrated an understanding around the needs of the current group of service users and provided positive interactions with service users. One member of staff provided sensitive support to one service user who was upset after talking to a relative on the telephone. No formal interviews were held with staff but in discussion with the Team Leader she was qualified to NVQ Level 3 and had completed training towards the Learning Disability Award Framework or LDAF as it is known. This was confirmed when sampling staff records. However, it was noted from sampling other staff records that not all staff had completed the LDAF programme. An examination of the staff rotas found that staffing levels during the evening were still unsatisfactory during the evening. The rotas also found that there
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 22 was not always two staff on duty during the day. One member of staff had left since the last inspection although two new members of staff had been recruited leaving one full time vacancy to be filled. Recent changes in staff have resulted in a number incidents of aggression regarding one of the service user particularly during the evenings, means that one member of staff on duty at that time is not acceptable and is placing other service users at risk. The manager had written to the individual service users’ social work teams for a review of their needs but had not received any response. As this is an outstanding requirement from the previous inspection; the CSCI may have to consider enforcement action to ensure compliance. Consideration must also be given to develop a picture board to assist service users in identifying who is on duty to reduce any undue anxiety. An examination of the staff recruitment records found to be satisfactory with one exception. Two files sampled had information including job description, induction record, contract, job application form, CRB check two references, photo and passport. One file sampled of a recently employed member of staff did not have confirmation that they had an up to date CRB check. The expert by experience asked two of the service users if they were involved in the recruitment of new staff. They confirmed that they took part in the interview and had a final say who was to work with them and that they liked their staff. Records were in place for staff training and it was found that the majority had completed mandatory topics such as manual handling, food hygiene, first aid, infection control, fire safety and food hygiene. Staff had also completed training in areas such as medication, adult protection and physical intervention. Since achieving registration the Registered Manager had completed training in physical intervention, meeting one of the registration conditions of the service. There was evidence of certificates of training completed on individual staff records. Further sampling of staff records found that they were receiving supervision every two months and each member of staff had a supervision contract. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, 41, 42 There is an open, relaxed and friendly atmosphere that benefits service users and staff. The organisation must be more frequent in ensuring service users and staff views about the service are heard. The records although up to date must be more streamlined for effective recording and storage. Service users health and safety is promoted and maintained with some improvements required. EVIDENCE: The manager was on annual leave at the time of this inspection and the inspector spoke to the Team Leader who was able to demonstrate a knowledge and understanding with regard to the needs of the service users. She described the manager as being supportive and always taking time to explain matters and there was a good working relationship between staff colleagues. The atmosphere was found to be quiet but relaxed and friendly. The expert by experience thought that staff and service users were very welcoming and offered her drinks and biscuits. Staff meetings do occur but not on a monthly basis.
Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 24 A representative from the organisation visits the service but not every month. The organisation must ensure these visits occur more frequently so that service users and staff are able provide comments as to the management of the service. While the records were generally up to date the manager must ensure some of the care records dating after 2002 are archived in order for a more streamlined system of record keeping. Records with regard to health and safety were found to be satisfactory. There was evidence that a fire drill had occurred prior to this inspection. The fire alarms had been tested every week. Staff had received training in the prevention of fire. There was also a fire risk assessment in place. The manager had completed risk assessments for the unguarded gas fire in the lounges and those radiators that were uncovered. This was a requirement from the previous inspection. Risk assessments were also in place covering staff that work alone on the premises. As previously mentioned one of the service users’ beds was found to be against the radiator and action must be taken to undertake a risk assessment and cover the radiator if necessary. The kitchen was found to be clean and tidy. Daily records were being maintained for the refrigerator and freezers. Another requirement addressed by the manager was the introduction of a daily occurrence book. The accident book was examined and it was noticed there had been twelve recorded since the last inspection. However, the majority of these related to one service user’s behaviour rather than falls or other injuries that there were no significant numbers. The accidents and other incidents had been notified to the CSCI via Regulation 37 notification. Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 2 x x Standard No 22 23
ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x 3 x 3 2 3 Standard No 11 12 13 14 15 16 17 x 2 3 2 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 1 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Castle Lane, 126 Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 2 3 x E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 26 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 6 Regulation 15(1)(2) Requirement The Registered Person must ensure service users care plans state how the identified needs of service users are to be met including the attendance of healthcare appointments. The Registered Person must ensure that reviews of service users care plans involve the service users and that an action plan is in place following the reviews The Registered Person must ensure that service users person centred plans are more specific regarding service users leisure interests. The Registered Person must ensure that service users have access to a printed copy of the minutes taken. Service users must be given the opportunity to prepare meals. The Registered Person must ensure that service users have the opportunity to go on a holiday of their choice anytime of the year. The Registered Person must ensure the food intake records are completed in full and that Timescale for action 16 October 2005 2. 6 15(1)(2) 16 October 2005 3. 6 12(3) 15(1) 16 October 2005 4. 7 12(3) 16 October 2005 5. 14 16(2) (m) (n) 16 October 2005 6. 17 Schedule 4 13 16 October 2005
Page 27 Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 7. 19 12(a) 8. 20 13(2) 9. 22 22(1) 10. 29 22(n) 11. 33 & 4 18(1)(a) 12. 33 12(3) 13. 34 19(1) (a) (b)(i) (2) indicates the choice of drinks offered to service users at suppertime. The Registered Person must ensure that the yearly health check records for service users are up to date. The Registered Person must ensure that the medication procedure is updated to reflect current practice under the Royal Pharmaceutical Society as the current procedure produced by Robinia is unsatisfactory. The Registered Person must ensure that the complaints procedure is available in a more accessible format for service users. It must state that service users will not be victimised for making any complaints and that the CSCI can be contacted at anytime. The Registered Person must ensure that hand rail is fitted to the patio door to enable service users with mobility difficulties to access the garden. The Registered Person must ensure it maintains adequate staffing levels that give service users greater choice and flexibility in their daily living activities, thus enabling them to access a wider range of social activities and address any changes in their needs. Outstanding Requirement. Timescale 15 March 2005 not met. The Registered Person must give consideration to the development of a suitable picture board to assist service users in identifying which staff are on duty. The Registered Person must ensure that confirmation of CRB 16 October 2005 16 November 2005 16 November 2005 16 November 2005 16 November 2005 16 November 2005 16 October 2005
Page 28 Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 14. 42 Schedule 2 (6)(7) 13(4) checks are in place on staff recruitment files. The Registered Person must ensure that steps are taken to risk assess the uncovered radiator in one of the service users bedroom to minimize the risks of scalding. 16 October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 27 Good Practice Recommendations It is recommended that consideration be given to providing an en-suite shower room in the garage conversion in preparation for if the mobility of the service user occupying the room deteriorates to the point where she can no longer safely negotiate the stairs to get the bathroom. Not assessed at this inspection but this has been brought forward from 15 February 2005 Castle Lane, 126 E54 S43658 Castle Lane 126 V242102 160805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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