Inspection on 10/11/05 for 20 - 32 Horton Street

This inspection was carried out on 10th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 35 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

20 - 32 Horton Street 04/12/08

20 - 32 Horton Street 15/08/06

20 - 32 Horton Street 23/06/05

20 - 32 Horton Street 21/12/04

20 - 32 Horton Street 10/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Horton Street West Bromwich West Midlands B70 7SG Lead Inspector Deborah Sharman Unannounced Inspection 10th November 2005 08:30 Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 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 Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 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. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Horton Street Address West Bromwich West Midlands B70 7SG 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 415 2720 0121 472 8449 Sense Jeanette Willis Care Home 7 Category(ies) of Sensory impairment (7) registration, with number of places Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: Horton Street is a new purpose built residential care home which opened on 9 December 2002. Care is provided by Sense and the building is owned and maintained by a Housing Association, Black Country Housing. The home is registered with The Commission for Social Care Inspection to provide care and accommodation for 7 adults with a learning disability and associated sensory disabilities. The home has 6 single bedrooms in the main body of the home. Each bedroom has an ensuite with toilet, basin and accessible shower. The home also has a kitchen, lounge, dining room, laundry, 2 bathrooms, (one upstairs and one downstairs). The downstairs bathroom is an assisted bathroom. There is a separate laundry and staff sleep-in room. The home also has a flat that has a lounge, kitchen, bathroom and bedroom. The flat is accessed via its own front door from the street but is considered to be part of the home. The premises have a large rear garden that is grassed and paved. The home is situated in an industrial area that is due to be regenerated. Its position is convenient for shops in the immediate vicinity, West Bromwich Centre, the Metro to Birmingham and Wolverhampton, Sandwell Valley and swimming in Halesowen. The home has its own minibuses to enable access to community facilities. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection meaning that the proprietor, manager, staff or service users did not receive prior notification and were not able to prepare. One Inspector conducted the inspection, which began at 8.30am and finished at 2.30pm. The plan was to assess those remaining core standards that were not assessed at the previous inspection. In addition it was planned to assess the management of hazardous chemicals following an incident with a service user in August 2005. It was further planned to assess progress against previous requirements issued to improve aspects of performance relating to only those Standards planned for assessment and others where time would allow. Those not assessed have been marked as such and where it is judged that previous requirements have been fully met these have been deleted from this report. Service users who live at Horton Street are deaf and blind with associated severe learning disabilities and are not able to verbalise there feelings to the Inspector about the experience of living at Horton Street. The Inspector was able however to speak to the Manager and a staff member in some detail as wall as assess documents and tour the environment. Judgements about the performance of the home have been made with the needs and best outcomes for service users at the forefront of the decision making process. What the service does well: The service continues to be homely and calm. The manager is continuing to work to improving the service by working closely with regulation and several previous requirements have been met. A staff member spoken to demonstrated an excellent knowledge of Adult Protection issues including a working knowledge of what her role and responsibilities would be in the event of a protection concern or allegation. The staff member also had an excellent working knowledge of risk assessments including what risk assessments are, the rational for them and was able to give clear examples of risk assessments in place for the protection of service users at Horton Street. Quality assurance systems continue to be good with no change from previous assessments. The management of service users finances is also good with systems in place to account for expenditure and to protect the financial interests of service users. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Whilst a significant number of previous requirements have been met indicating improvement and progress, required development has not been evidenced where a corporate response has been required to for example review and up date policies (e.g. Whistle blowing, Adult Protection) and to write an infection control policy. Most documents were in place to show that the premises and equipment are regularly serviced and safe but bacteriological certificates remain unavailable and the Gas Landlord certificate to show that gas appliances have been serviced appropriately had expired two months prior to inspection. The proprietor needs to ensure that there is evidence available to demonstrate that induction training provided to new staff complies with the appropriate national standard. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 7 The most significant concern arising from this unannounced inspection was in respect to the management of hazardous chemicals. Concern was such given the identified needs of service users that an immediate requirement for improvement was issued to safeguard service users. There had been an incident in August where a service user consumed liquid soap. It is disappointing that this serious incident had not lead to better vigilance and practice. The manager however welcomed the opportunity that this surprise inspection gave to identify and improve omissions in practice. This will be kept under review. 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. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection although the Statement of Purpose has been amended to include those omissions previously required. It is recognised that Horton Street is providing a service for service users with learning disabilities associated with sensory impairment but it has come to the Inspector’s attention that the home did not apply for this registration category and as such is not technically registered to provide a service for people with learning disabilities. Furthermore the Statement of Purpose states that the home provides a service for ‘additional learning disability and / or mental health difficulties’. The home is not registered to provide a service for service users with mental health needs. Categories of registration and the Statement of Purpose accordingly require review. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Risks are identified and action generally is taken to minimise them. However, significant omissions in some systems and practice has risked harm to service users. EVIDENCE: A staff member spoken to demonstrated a very good knowledge of what risk assessment is, how it works and gave some examples of risk assessments in place to minimise risks to service users including keeping cupboards locked that store chemicals. Cupboards were however found to be unlocked in spite of a notice on the cupboard. COSHH assessments are not in place but have been delegated to the Deputy manager to do. A data sheet was not available for one product found accessible in the toilet. Practical steps have been taken to minimise risk following the accident a service user had in August by consuming liquid soap e.g. the cabinet containing toiletries has been removed from his room but a formal risk assessment made known to staff has not been undertaken to ensure that toiletries etc are not inadvertently left there or to identify the risks of chemicals elsewhere in the building. Likewise a risk assessment has not been undertaken in respect of an incident subject to a regulation 37 notice Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 11 whereby a service user who was thought to have taken his medication only for it to be found on the floor later. Many risk assessments are however in place and the manager said she is beginning to risk assess everything mentally prior to making a decision. For example a pill crusher purchased has been discarded prior to use as it has been determined that there is a risk that some of the crushed medication would be wasted and would result in the administration of less than the full prescribed dose. Eating and drinking risk assessments have been undertaken by visiting specialists in respect of each service user and guidelines for staff to minimise risk have consequently been developed and are available. The Inspector was informed too that nutritional risk assessments are now in place for each service user representing an improvement although these were not assessed at this inspection. Staff must implement safety strategies put in place to protect service users. Since the last inspection the manager has shared risk assessments with external services they work with who provide activities for service users. This is good practice. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. Following previous requirement the Inspector and Manager entered the bathroom where the medication is stored to assess whether room temperatures are being taken to ensure that medication is being stored at safe temperatures (temperatures were found to be compliant). The medication cupboard on the wall was wide open and unattended (the staff member was administering medication in the body of the home). A service user was seated opposite the bathroom in his bedroom and could have entered the bathroom unnoticed which had not been secured, placing him at risk. The staff member responsible was spoken to and was aware of the error made. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The provider has demonstrated a positive response to the receipt of complaints and a commitment to complaint resolution. The manager has developed a confident working knowledge of her role upon receipt of an allegation. As none of the previous requirements to improve policies and procedures have been met sufficient written guidance is not available. EVIDENCE: The home has received complaints since the last inspection about noise levels. The provider has investigated this and responded positively to the Commission for Social care Inspection and to the complainants. Appropriate action has been taken and further proposals for the resolution of the complaints have been offered by the provider that need discussing with the complainants. There have been a number of similar complaints over a period of time but each one had not been logged as the manager defined them as the same complaint. It is important that each complaint is recorded even if it is about the same issue. Written guidance for complainants is now improved and complaints guidance is available in the entrance to the home. Since the last inspection there have been incidents (one which did not take place at the home but involved one of the home’s service users), which have been referred to the adult protection arena and were notified to the Commission appropriately. A staff member has been suspended and remains suspended pending investigation. A report outlining the investigation process and outcome must be submitted to the Commission for Social Care Inspection upon conclusion. The manager advised the Inspector that a decision has been Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 15 taken not to refer the staff member temporarily to the POVA list and the Inspector advised that this decision be reviewed or explained. A requirement was made following the March 2005 inspection to put a protocol in place in consultation with Social Services in respect of a service user who frequently makes allegations. This requirement has not been met and whilst not on the home’s premises as an adult protection allegation has been made. It is particularly important that this is now addressed without delay. None of the outstanding requirements to improve the Adult Protection policies have been met. A staff member who has received adult protection training demonstrated a very high degree of understanding in respect of a range of adult protection issues and was able to correctly identify action she should take in a range of hypothetical scenarios. Systems are appropriately in place to manage service users finances. Cash in hand was checked by the Inspector and tallied with written records. Receipts are kept to account for expenditure. Two staff sign to authorise expenditure and monies held are checked and signed for at each staff handover. Written guidance states that ‘residents personal money (except DLA) must never be used for anything other than the direct benefit of the individual whose money it is’ Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The premises are suitable for purpose and are generally homely and comfortable but outstanding redecoration required following a water leak is yet to be done. The premises are also generally safe but significant omissions provide risk to service users. Some aspects of infection control have improved. EVIDENCE: Horton Street is comfortable, clean, accessible and homely. Redecoration and carpet replacement required as a result of a long-term water leak remains required but the Inspector was assured that this is in hand. The premises are generally safe and well maintained although the Gas Landlord certificate had expired 2 months prior to inspection and a report is not available to evidence that water samples have safe levels of bacteria. Infection control was not fully assessed but action has been take to improve aspects of laundry management e.g. the Infection Control nurse has done an audit and whilst she is happy with practice has recommended that the laundry be half tiled and this is in hand. Aprons and hand washing signage are now available in the laundry as well as covered laundry boxes to minimise the risk of cross infection. Appropriate bags to transport soiled linen have also been purchased and have been made available to each individual service user. The home continues not to have an infection control policy. Staff were not wearing Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 17 aprons in the kitchen and this requirement therefore remains unmet. A Food Safety visit was last undertaken by the Environmental Health Department in December 2003 where it was required that different coloured aprons for personal care and food are used. One colour for both remains available. The last visit from the Fire Service was in 2002. It is a long-standing requirement to provide a loop system to help improve hearing for some service users in communal areas of the home. This remains not provided but it has been decided that the home will fund the work to ensure improvement and again the manager said that this is now in hand. The requirement to fix a service users wardrobe to the wall in his bedroom has been met making this safer for him but COSHH (hazardous chemicals) mismanagement identified at this inspection has compromised the safety of service users. The home has received three quotes to knock the separate flat through to the main body of the home with a view to ensuring access for night staff to eliminate the need for the sleeping night staff following the increase of waking night staff from one to two. Given recent reportable events, the layout of the building and the needs of the service users the inspector expressed concerns about this proposal. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 EVIDENCE: The previous requirements in respect of training have been met. Fire training has improved and is being provided twice per year now by a trainer and via a recently acquired video which is being used ‘in house’. Fire training is also now included on the team’s training matrix to ensure that it is not overlooked. Not all adult protection training certificates are available as the manager said that staff are not bringing them in from home. Further adult protection training has however been booked between now and March with Sandwell Social Services. An interview with a staff member employed at the home for two years showed that a wide range of appropriate training has been provided. With the exception of Food Hygiene training the staff members verbal account of training undertaken tallied with the homes matrix record. It appears that the only omission in this staff members training is Food Hygiene and the manager will investigate this. From the records available it appears that staff are receiving the minimum of 3 training days required by national standard per year. Certificates however were not available as evidence as the staff member’s personnel file was not available as it must be. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 19 The provider must provide evidence that the home’s induction complies with nationally agreed minimum standards e.g. The Learning Disability Awards Framework. It is this, which is preventing the training standard being judged as fully met. (The home has received three quotes to knock the separate flat through to the main body of the home with a view to ensuring access for night staff to eliminate the need for the sleeping night staff following the increase of waking night staff from one to two. Given recent reportable events, the layout of the building and the needs of the service users the inspector expressed concerns about this proposal.) Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Service users needs continue to underpin all self-monitoring and developments made by the manager and provider. The safety of service users is generally protected with omissions in gas maintenance and the management of hazardous chemicals and storage of medication undermining the welfare of service users. EVIDENCE: Quality Assurance processes were last assessed in March 2005 and were judged as fully met. There have been no changes to this system where the provider audits performance based on service user and relative feedback every two years. In between these provider assessments the manager is expected to undertake a self-assessment and this is due imminently (January 2006). All service maintenance records were in place with the exception of water bacteriological levels and the Gas Landlord certificate had expired. A Fire Risk assessment is in place but the manager said that this is going to be reviewed and improved on 29.11.05 when a fire risk assessment for each service user will be undertaken. An Emergency plan, which the Fire Service is beginning, to request is not in place. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 21 Ten day staff have first aid awareness qualifications and the manager and Deputy manager also are first aid qualified. Three more staff are booked to attend first aid training in the new year. All staff have done infection control training and most staff have done Food hygiene training. All staff did fire training in February and November 2005. There are some omissions in risk assessments required (see Standard 9) Accident records were available and were sampled with outcomes showing that all changes are being noted including scratches etc. Most of the records detail self injurious known behaviours of service users. COSHH management was the most significant concern arising from this inspection. In August 2005 there was an incident reported to the Commission for Social care Inspection under Regulation 37 where a service user consumed a COSHH product, liquid soap. A further service user is also inclined to search for things to eat and does so indiscriminately. These behaviours are being reviewed by psychology input but in the meantime risk must be minimised. Two lockable COSHH cupboards in the laundry were not locked. One on the wall contained 4 bottles of sun lotion and carpet maintenance powder. The bottom cupboard, which was not secured but had keys left in, contained a variety of cleaning materials including bleach. A member of staff was interviewed who demonstrated knowing that the COSHH cupboard should be locked at all times. The toilet room had two aerosol air fresheners stored on a low level shelf which were accessible to all. One was an Asda air freshener for which there is a data sheet. The other was Johnson’s ‘Oust’ for which there was no data sheet. Neither had COSHH assessments. The principles of COSHH risk assessment were discussed with the manager including the need to reduce COSHH risk to its lowest factor by removing or changing products which are high risk and / or unnecessary. For example the need for canister air fresheners was queried given the wall ‘puffa’ systems employed by the home. The manager felt that staff had purchased the Johnson product from Asda rather than the product for which there is a data sheet due to lack of understanding of the implications. The Inspector and Manager entered the bathroom where the medication is stored to assess whether room temperatures are being taken to ensure that medication is being stored at safe temperatures (temperatures were found to be compliant). The medication cupboard on the wall was wide open and unattended (the staff member was administering medication in the body of the Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 22 home at the time). A service user was seated opposite the bathroom in his bedroom with the door open and could have entered the bathroom unnoticed which had not been secured, placing him at risk. The staff member responsible was spoken to and was aware of the error made. Toiletries are stored in some bedrooms for two service users without being locked away. Whilst steps have been taken since the incident in August to remove the storage of COSHH from the bedroom of the service user affected, the accessibility of COSHH products in other parts of the home have not been risk assessed since this serious incident. The need to provide COSHH training for staff was agreed with the Registered Manager. Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 23 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 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Horton Street Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 1 X DS0000037211.V266041.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The homes categories of registration require review in consultation with the Commission for Social care Inspection. The home’s Statement of Purpose must reflect the categories that the home is registered for. The home must not admit service users funded by Local Authorities prior to receipt of a completed Community Care Assessment Upon Next Admission (No new admission) The home must provide a contract of terms and conditions between the resident and the home. The contract must cover all areas as defined in Standard 5. (Settling in period must be changed from 4 to 12 weeks. Fee must be included and completed) Not Assessed at this inspection. DS0000037211.V266041.R01.S.doc Timescale for action 31/12/05 2 YA1 4 30/11/06 3 YA5 5(b) 31/03/06 Horton Street Version 5.0 Page 25 4 YA5 5(b) 13(6) The provider must review the 31/03/06 funding for the home’s transport given that the contract states that the fee includes transport costs and yet 50 of the service users mobility allowance is being taken to pay for transport costs in addition to the fee. New Requirement June 2005 5 YA6 6 YA7 Not assessed at this inspection. 15,sch3(m) The manager must ensure: 31/12/05 · Appropriate care plans are produced · A written record is kept of reviews of care plans Requirement first made December 2004 and not assessed at this inspection. 31/12/05 12(2) Staff must demonstrate how individual choices have been made and must record instances when others make decisions on behalf of service users. (New recording system introduced to encourage this. More training for staff required in its use.) Not assessed at this inspection. The manager must undertake 30/11/05 risk assessments to ensure the adequate supervision and privacy of the resident in the flat when the sleep in post terminates (replaced by extra waking night staff). Proposal not progressed at this inspection Risk assessments in place to prevent the risk of drowning whilst in the bath must be extended to consider the risk of drowning in circumstances other than whilst bathing. 7 YA9 13(4) Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 26 8 YA9 13(4) 13(7) Requirement first made March 2005. All staff must sign the risk assessment re bolt external to bathroom door) and associated safe system to acknowledge understanding. (2 staff signed at June 2005) Not assessed at this inspection although one staff member verbally recounted this. The confidentiality policy must be updated (still refers to Registered Homes Act) Families and stakeholders must be provided with access to the homes policy on confidentiality when updated. Requirement first made March 2004 Any restrictions appertaining to voting must be accounted for in the plan of care. New Requirement June 2005 Not assessed at this inspection. Contact needs with friends and family must be formally assessed for each service user, planned for and monitored. New Requirement at June 2005 Not assessed at this inspection. All service users to have a comprehensive nutritional assessment that is reviewed regularly and appropriate action taken Format obtained but not completed DS0000037211.V266041.R01.S.doc 30/11/05 9 YA10 17(1)(b) 31/03/05 10 YA13 15, 12(2)(3) 31/03/05 11 YA15 12 31/12/05 12 YA17 12 31/12/05 Horton Street Version 5.0 Page 27 Requirement first made December 2004. Not assessed at this inspection. The manager to ensure that service users are weighed at the appropriate times identified in their assessment (Not met for service user case tracked) Requirement first made December 2004 Not assessed at this inspection. Arrangements must be made to ensure that the need for ear syringing assessed as required for service user ‘S’ is regularly reviewed by a medical practitioner and evidenced. New Requirement at June 2005 Not assessed at this inspection. Medication policy must state that in the event of death medication must be retained for 7 days. A written policy in respect of homely remedies must be established. (GP would not give approval – homely remedies since withdrawn from use and must be confirmed in completed policy) Not Assessed at this inspection A multi-disciplinary decision to administer medication covertly must be obtained and recorded with signatures where possible. (Manager said this discussed at review 13.6.05 – notes not DS0000037211.V266041.R01.S.doc 13 YA19 12 31/07/05 14 YA19 12, 13 30/11/05 15 YA20 13(2) 31/12/05 16 YA20 13(2)(4) 31/12/05 Horton Street Version 5.0 Page 28 available at inspection June 05) Not assessed at this inspection. The manager must ensure: · A covert medication policy must be produced Requirement first made December 2004. Not assessed at this inspection. Medication stocks must be reviewed and excess stock returned to the pharmacist for disposal. Prescribed medications / supplements must be discontinued only upon the advice of a medical practitioner. The advice must be recorded. Expiry dates on all medications /creams / drops must be complied with. Not assessed at this inspection. The medication cupboard must be kept locked at all times and must not be left unattended when unlocked at any time. New Requirement at November 2005. All complaints/comments must be recorded At November 2005 repeated complaints about same issue not all recorded A separate and robust policy and procedure on Whistle blowing must be developed. 17 YA20 13(2) 30/11/05 18 YA20 13(2) 30/11/05 19 YA20 13(2) 10/11/05 20 YA22 22 30/11/05 21 YA23 13(6) 30/11/05 Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 29 The Adult Protection Policy must be reviewed in respect of its position re Criminal Bureau Record checks for permanent staff and volunteers (on short breaks) A copy of the Department of Health’s ‘No Secrets’ must be available within the home. A copy of Sandwell’s multi agency Adult Protection procedures must be available within the home. Adult Protection training certificates must be held at the home PART MET Requirements first made March 2005 and not met at this inspection November 2005. The manager must contact Social Services in respect of the resident whose behaviours include making allegations to agree and develop a risk assessment and protocol for the protection of both the resident and staff. (Social Services approached but protocol not in place) Requirement first made March 2005 and protocol not in place at this inspection November 2005. This requirement must be met prior to the readmission of this service user to the home. A loop system must be provided in communal areas of the home. (On waiting list) Requirement first made December 2003 and not met at this inspection November DS0000037211.V266041.R01.S.doc 22 YA23 13(6) 10/11/05 23 YA29 23(1)(a) 23(2) 31/03/06 Horton Street Version 5.0 Page 30 2005. 24 YA30 13(3) Staff working in the kitchen 10/11/05 must wear an apron at all times. Requirement first made March 2005 and not met at this inspection November 2005. Personal care and Food handling aprons must be differentiated by colour as per the Environmental Health Report 2003. New Requirement at November 2005. The home must develop an 31/03/06 Infection Control policy. Requirement first made March 2005 and not met at this inspection November 2005. 25 YA30 13(3) 26 YA33 18 Staffing levels must be maintained at all times. New requirement at June 2005. NOT MET AS REG 37 RECEIVED IN RESPECT OF NIGTH STAFF LEVELS SINCE LAST INSPECTION. The manager must ensure that any supplying staff agency confirms in writing for individually named staff prior to the supply of any staff that all appropriate employment checks have been obtained including the Protection of Vulnerable Adults Checks. New requirement at June 2005. Requirement first made at March 2005 and not assessed at this inspection. 10/11/05 27 YA34 19 30/11/05 Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 31 28 YA35 18 Evidence of how induction for new staff complies with LDAFF must be forwarded to the Commission for Social Care Inspection. New Requirement at November 2005. All staff must be provided with COSHH training. This must be completed by the date set. New Requirement at November 2005. Copies of bacteriological certificates must be provided to the Commission for Social care Inspection Requirement first made March 2005 and not met at this inspection November 2005. The manager must seek the advice of the West Midlands Fire Service about plans to link the flat with the main body of the home via an added internal door. NOT MET / NOT CHANGED YET AT NOVEMBER 05 Requirement first made at March 2005 Plans re the above must be decided upon and confirmed in writing to the Commission for Social care Inspection prior to actioning. New Requirement at November 2005. The Registered Manager must with immediate effect (i.e. prior to leaving the premises) ensure the immediate safety of service users to protect them from the risk of COSHH product DS0000037211.V266041.R01.S.doc 31/12/05 29 YA35 18 31/03/06 30 YA42 23 31/12/05 31 YA42 23(4) 10/11/05 32 YA42 13(4) 11/11/05 Horton Street Version 5.0 Page 32 accidents. The Registered Manager must take action to ensure compliance with the Control of Substances Hazardous to Health Regulations 1999. The Registered Manager must confirm in writing to the Commission for Social care Inspection, with evidence action taken to meet the above requirements by Friday November 11th 2005 at 4.30pm. NEW IMMEDIATE REQUIREMENT AT THIS INSPECTION NOV 05. COSHH assessments with control measures must be undertaken for all COSHH products on the premises using data sheets which must be available for all products stored New Requirement at November 2005. A current up to date Gas Landlord certificate must be available a copy of which must be forwarded to the Commission for Social care Inspection. New Requirement at November 2005. An emergency plan for the home must be developed. New Requirement at November 2005. 33 YA42 13(4) 30/11/05 34 YA42 13(4) 23 30/11/05 35 YA42 23 (4)© (iii) 31/12/05 Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 33 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Horton Street DS0000037211.V266041.R01.S.doc Version 5.0 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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