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Inspection on 15/08/06 for 20 - 32 Horton Street

Also see our care home review for 20 - 32 Horton Street for more information

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to be calm, clean and homely. Managers continue to demonstrate motivation to help the home to develop and a number of previous requirements have been fully met and have therefore been deleted from this report. Outcomes for service users are good with their being evidence that service users are supported to lead fulfilling and busy lives. Systems to support record keeping are good and help to guide good care and well evidence the care provided. The Manager continues to seek creative ways to improve systems to help staff to meet service users needs. Particularly impressive is the production of photographic step by step guidelines in the use of the hoist for a service user who has started to be hoisted since the last inspection.

What has improved since the last inspection?

Many outstanding previous requirements have been met demonstrating that the home continues to move forward. Systems to assess service users nutritional health have commenced including the regular checking of service users weights in accordance with the level of risk identified. All requirements previously issued in relation to medication practice have been met reducing risk to service users. All hazardous chemicals were found to be appropriately stored at this inspection also reducing significant risk to service users. Requirements relating to infection control have also been met. Staff were observed to be wearing aprons in the kitchen and there is now a separate supply of aprons for food handling and personal care reducing the risk of cross infection. An infection control policy has been produced and although this remains in draft a copy is available within the home. This reduces the risk of services users becoming ill from avoidable infection. Specific risk assessments required to identify risk to service users have been completed since the last inspection too.

What the care home could do better:

There were three main significant concerns arising from this inspection. There is sufficient evidence from the outcomes of recent events and disciplinaries to demonstrate that in the absence of the manager and deputy manager that systems are not sufficiently in place to ensure the adequate management of staff on a day-to-day basis. The home does not have any senior care staff to take responsibility for the efficient and effective running of shifts potentially putting service users at risk. The rota has been poorly managed. Changes to staffing have not been included on the rota and therefore this document does not effectively plan staffing required or demonstrate staffing arrangements accurately.Since the last inspection procedures to ensure that agency staff used have been appropriately checked have improved. However there were omissions in documentation for an agency staff member on duty at the time of inspection. Documentation to demonstrate sufficiency of recruitment checks were not available, the staff member was not carrying any identification with her breaching locally agreed protocols and she was neither included on the staff rota. This was subject to immediate requirement. Although investigation since inspection has shown that the agency held the documentation showing that checks had been appropriately carried out minimising risk to service users evidence was not available to the home or Inspector at the time. This breach in systems indicates that there is the potential for future risk to service users.

CARE HOME ADULTS 18-65 20 - 32 Horton Street West Bromwich West Midlands B70 7SG Lead Inspector Deborah Sharman Key Unannounced Inspection 15th August 2006 09:30 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 20 - 32 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 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th November 2005 Brief Description of the Service: Horton Street is a 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 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. The weekly fee is: This information was not provided to CSCI prior to inspection. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection meaning that nobody associated with the home was given prior notification of the intention to inspect and they were therefore unable to prepare. One Inspector carried out the inspection which began at 8.15am and finished at 7.45 pm. The purpose of this inspection was to assess performance against key National Minimum Standards and to assess progress towards all of the previous outstanding requirements previously issued to ensure improvement. A range of methods was used to gather evidence and form judgements about the quality of the service provided. The home pre inspection provided he Inspector with written information about any changes within the home and aspects of this information were followed up during the inspection. The Inspectors knowledge of incidents, which have taken place since the last inspection, were also followed up. The General Manager, Homes Registered Manager and a staff member supported the process of the inspection throughout the day answering questions and providing documentation. The care provided to one service user was case tracked. It was not possible to interview service users who are all non vocal and although they were out on planned activities for most of the day there was some opportunity to observe interaction between staff and service users. The meal provided at tea time was seen and observed to be a calm and relaxing time. In addition the Inspector toured the premises and assessed progress made towards complying with previous requirements issued to promote the homes development. The Inspector also followed up some aspects of a complaint made known to CSCI prior to inspection which had been investigated by the provider. It is judged that the home is overall providing a good level of service to service users who are supported to lead fulfilling lives and whose health needs are met. The home currently has a service user vacancy. What the service does well: The home continues to be calm, clean and homely. Managers continue to demonstrate motivation to help the home to develop and a number of previous requirements have been fully met and have therefore been deleted from this report. Outcomes for service users are good with their being evidence that service users are supported to lead fulfilling and busy lives. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 6 Systems to support record keeping are good and help to guide good care and well evidence the care provided. The Manager continues to seek creative ways to improve systems to help staff to meet service users needs. Particularly impressive is the production of photographic step by step guidelines in the use of the hoist for a service user who has started to be hoisted since the last inspection. What has improved since the last inspection? What they could do better: There were three main significant concerns arising from this inspection. There is sufficient evidence from the outcomes of recent events and disciplinaries to demonstrate that in the absence of the manager and deputy manager that systems are not sufficiently in place to ensure the adequate management of staff on a day-to-day basis. The home does not have any senior care staff to take responsibility for the efficient and effective running of shifts potentially putting service users at risk. The rota has been poorly managed. Changes to staffing have not been included on the rota and therefore this document does not effectively plan staffing required or demonstrate staffing arrangements accurately. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 7 Since the last inspection procedures to ensure that agency staff used have been appropriately checked have improved. However there were omissions in documentation for an agency staff member on duty at the time of inspection. Documentation to demonstrate sufficiency of recruitment checks were not available, the staff member was not carrying any identification with her breaching locally agreed protocols and she was neither included on the staff rota. This was subject to immediate requirement. Although investigation since inspection has shown that the agency held the documentation showing that checks had been appropriately carried out minimising risk to service users evidence was not available to the home or Inspector at the time. This breach in systems indicates that there is the potential for future risk to service users. 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. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 The performance outcomes for choice of home are poor. Information available for service users and their representatives prior to admission is not sufficiently accurate and potentially misleading. Systems are not sufficiently developed to assess prospective service users needs. Whilst the omissions are few in number together they are significant in potential effect on service users. EVIDENCE: One service user has left Horton Street on the basis that the home could no longer meet his needs in spite of considerable effort and liaison with multi disciplinary professionals in an attempt to do so. There is therefore a service user vacancy. A service user has been identified for this vacancy and steps are being taken for her transfer from another Sense home that is closing. The involvement of Social Services as Commissioners and assessors of need is not known to Horton Street and although the home has had active contact and involvement with the proposed new service user the Manager has not carried out a formal assessment of need. Written information has been provided by the service users existing home but it is important that the Horton Street Manager carries out her own assessment to be sure that Horton Street can meet identified needs. The service user has had several trial visits but these have not been documented or formally evaluated. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 10 Contracts now state that a 12-week extended settling in period is provided although significant information such as fees remain not included. Contractual statements still contradict practice i.e. contracts state that transport is included in the fee and yet 50 of service users mobility is deducted towards transport costs. There is a Statement of Purpose. The home’s Statement of Purpose does not however accurately reflect the service user categories that the home is registered for ie the home is not registered to accommodate service users with mental Health Needs as stated. The home is required to apply for a minor variation to include Learning disability in its registration as well as sensory impairment to accurately reflect the needs of service users accommodated who have both sensory and learning needs. The Manager has had little experience of new admissions to Horton Street as there has been a permanent and long-term service user group resident there. The Manager verbally explained procedures for admitting a service user externally referred to Horton Street but had handled this referral differently because the service user already receives a service from Sense. It is important that procedures are adhered to in order to independently ensure that Horton Street is an appropriate placement as this remains the Managers responsibility. The Manager received constructive advice positively and stated that she would meet the omissions identified prior to the proposed service users admission. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The performance outcomes are good with there being more strengths than weaknesses. Detailed care plans, risk assessments and systems to support none vocal service users provide staff with good guidance as to how to meet their needs. EVIDENCE: The requirement to improve care plans remains because although they are generally good with more strengths than weaknesses some omissions remained. Service user financial arrangements were not included in care plans but this was addressed during the course of the inspection. Also although nutritional assessments have now been undertaken care planning in response to this is insufficient. Medical advice has not been sought for example to determine healthy weight ranges for service users so that care can be provided and planned for in relation to some benchmarking for individuals. Multidisciplinary reviews of service users care are now better evidenced with excellent records which identify new goals. Reviews however are due and overdue but the Manager is aware of the need for this and explained that extenuating circumstances had lead to planned reviews being cancelled. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 12 Records demonstrating how none vocal service users are helped to make choices and decisions have improved with one record showing how a service user had been prompted to get up several times but his refusals had been respected and noted. It is clear from practice that service users are offered choices continually and tools are available to support them to do so including choice boxes, calendar boxes and portable equivalents containing objects of reference. It is accepted that it is difficult to evidence the amount of choices offered, as it is endemic to practice. However although limitations on some aspects of decision-making are noted e.g. voting and mail, choices made by others on behalf of service users on a day-to-day basis are not well accounted for and it was agreed that the Manager would support staff to improve this area. Multi disciplinary review meetings are well minuted with new needs and actions identified. Most but not all decisions identified as requiring action had been acted upon. Risk assessments in place for individual service users are good and previous requirements in relation to risk assessments have been met. For example risk assessments are in place for when service users are around water. This is particularly important as service users go swimming regularly and on barge trips. These risk assessments contain good detail to guide staff to minimise risk and include required staffing ratios during activities. A risk assessment which includes the use of a bolt on the bathroom door has now been read by staff and it clearly outlines that this is to be used as a safety measure to prevent access to the bathroom unsupervised and is not to be used as a restraint whilst the service user is in the bathroom protecting the welfare and interests of the service user considered to be at risk. Newly introduced guidelines for the use of the new hoist for one service user using home made photographs as a medium to aid communication to staff is a particularly effective and creative development which is considered to be excellent. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16, 17 The performance outcomes are generally good with service users having access to a wide range of in house and community activities of choice and preference. Activities are well evaluated. Assessing and meeting nutritional need should improve. However as a whole there are more strengths than weaknesses in performance. EVIDENCE: Records show that service users have a wide and varied activity programme which accesses local community facilities and which is evaluated well. Activities were case tracked for one service user. The activity programme complies with her preferred interests and highly developed systems are in place to measure whether service users are being supported to enjoy scheduled activities. Staff and the manager have to account for why scheduled activities have not taken place. Computer analysis shows the percentage of scheduled and alternative activities that take place monthly providing service users with assurance that activities provided to them are valued and managed well. Records for May show that 69 of scheduled activities took place for all service users and that for a week sampled in June the service user case 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 14 tracked took part in 10 out of a possible 14 activity sessions. Systems are in place to ensure that if a scheduled activity is cancelled that it is replaced with a ‘like for like’ alternative. There is evidence of good practice in supporting service users to maintain contact with family and friends. Staff drive one service user to London to see his family and there is good evidence that staff stay in telephone contact with this family member. Care plans have been reviewed since the last inspection to include family contact arrangements but were found to require further development and they did not contain sufficiently detailed guidance for staff. How contact must be maintained was not sufficiently clear and contact referred to as ‘regular’ was not sufficiently defined to guide practice. However following feedback this was addressed during the course of the inspection. Nutritional assessments have been carried out since the last inspection and risk is determined as ‘high’ for the service user case tracked. Care plans are unclear in respect of dietary health and do not sufficiently guide a plan of care to meet this high risk. Discussion showed the general perception to be that the service user requires a fortified diet but the care plan refers to a ‘balanced diet’ with no reference to fortification. Safe weight ranges or Body mass index measurements for service users are not known although records examined show weights to be maintained. The home has requested the advice of a dietician but this is proving difficult to secure although the provider could consider commissioning a private dietician. In the absence of a dietician alternative medical advice has not been sought. Staff were well aware of service users food preferences and records and stocks showed that the service user is provided with her favourite foods. Dysphagia training is planned to enable a staff member to assess and respond to eating and drinking needs. Mealtime was observed. Portions were good and meals were attractively presented. Mealtime was calm and orderly with help provided discreetly where required. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 Personal support and health care provision for service users is very good. The need to ensure that changes made to medications are only directed by the prescriber and are appropriately evidenced is preventing performance outcomes from being judged as excellent. EVIDENCE: Personal support and health care plans provide staff with excellent guidance to ensure that service users receive personal support and health services in the way that they prefer and need. There was good evidence that plans are adhered to as records for the service user case tracked showed that she has received health screening in accordance with her needs. There was also good evidence that changes in health are noted and responded to appropriately. Systems to improve the management of medication have been improved with all except one outstanding previous requirements having been deleted as met. An improved medication policy is available and now includes guidance in the event of death and for homely remedies. Decisions to administer medication covertly have been approved by a range of professionals at the service user’s review meeting. Medication stocks are no longer excessive and the Inspector observed the pharmacy collect excess stock on the day of inspection. Medical creams and drops were all dated and were within date. Significantly this 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 16 inspection found the medication cupboard to be locked at all times including during the administration period and a previous lapse has been appropriately dealt with. A further incidence of poor practice had been reported since the last inspection and disciplinary procedures were implemented appropriately. During the course of investigating this incident it came to the manager’s attention that staffs signing for medication were delegating the administration of the medication to other staff which is not appropriate. A new protocol has been put in place in response to a service user identified as spitting out medication. There have been no further incidents so action taken is ensuring that he is receiving correct doses of prescribed medication. This has been stopped. It remains for the manager to ensure that medications are only discontinued upon the advice of the prescriber and that this advice is recorded. There is evidence that medications have been discontinued upon the suggestion of the District Nurse and Speech and Language therapist rather than discussing advice given with the GP. All changes to medication must be accounted for to ensure instructions are clear to protect service users from the risk of under or overdosing. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 The performance outcomes are adequate. Service users and others can be assured their views are listened to and acted upon. Appropriate action is taken by management once they become aware of situations which are or potentially are adult protection in nature. However more could be done to prevent situations arising which place vulnerable adults at risk e.g. staff understanding of whistle blowing, obtaining and amending written guidance to appropriately guide staff, restructuring the staffing hierarchy etc. EVIDENCE: There is evidence that complaints are investigated and responded to. There have been 3 complaints since July 2005 and these are recorded. Action has been taken in response to these. The Manager must ensure that complaints however are more accurately recorded. Repeated complaints by the same person about the same issue must all be recorded and haven’t been. The date of when the complaint was received must be logged in full. Because for example it was not possible to judge whether complaints had been resolved within the required timescale as one had been logged in as ‘May 06’. Appropriate action has been taken involving partner professionals following incidents identified as adult protection and complex disciplinary investigations arising from these have been followed through. These investigations have highlighted unprofessional conduct of some staff in the absence of the manager. There is concern about how effectively service users were supervised during these incidents. Senior staff are not available to take responsibility for the management of each shift. Whilst the provider believes that immediate risk has been minimised staff structures must be amended to 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 18 ensure that staff are appropriately supervised at all times to ensure the protection and appropriate supervision of service users. There is not sufficient written guidance on the premises to support adult protection procedures. The previous requirement to develop the whistle blowing policy has not been met and the Inspector commented that staff had not acted quickly enough to report inappropriate behaviour amongst their group. The General Manager identified this during an investigation after there had been an incident. The provider believes the whistle blowing policy to be appropriate but plans a team away day to ensure staff understand their responsibilities. A copy of the Local Authority Multidisciplinary adult protection procedures is still not available on the premises and this has been required since March 2005. The homes own adult protection policy states volunteers can accompany holidays without being appropriately checked. This is not satisfactory. A review of this was required in March 2005 also and action has not been taken. Systems are not in place to ensure that staff provide adult protection training certificates so training cannot be evidenced for 3 staff. Service users monies and possessions are handled appropriately and good systems are in place to safeguard and maintain this. Cash held on service users behalf accorded with records held. Physical intervention is not used and ‘as required’ medications to control behaviour are also not prescribed protecting service users from the risk of overmedication as a result of behaviours. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 the following standard(s): 24, 30 Performance outcomes are generally good as service users live in a homely, comfortable and safe environment that is clean and hygienic. It is disappointing however that miner repairs and redecoration following unforeseen circumstances take so long to achieve. EVIDENCE: Horton Street is comfortable, clean, accessible and homely. The premises are generally safe with service documents being up to date. The exception to this was water safety where legionella risk assessments, and bacteriological reports were not available. A copy of the contract for water safety had previously been supplied to CSCI but there was no evidence of work being carried out. A telephone call to the contractor during the inspection resulted in an undertaking for them to visit the home the following day to undertake a water risk assessment. Following a water leak action has been taken to undertake repairs but redecoration is still required. This has taken 14 months to date. Since the last inspection there has been a further water leak from a first floor bedroom. Action has been taken to prevent the problem but more is required to finish the job e.g. reinstatement of shower doors and redecoration. The Manager said that this is in hand. Other than this there remain no changes to the environment but new flooring is planned for the dining room and the empty bedroom as well as the proposed purchase of new dining room table 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 20 and chairs. Issues raised in a recent complaint about the environment were assessed and no aspects were found to be outstanding. A hearing loop system required for communal areas since December 2003 has not been provided. This is poor as this home is registered for people with sensory impairment who are blind and deaf. The service user whom it was felt would benefit from this has broken the system in his bedroom so the value of a second is being questioned. This must be discussed at the service users next and imminent 6 month multidisciplinary review. Outcomes must be recorded and implemented. All aspects of infection control are now well managed with there being evidence of some improvements. The laundry has been partly tiled to make cleaning easier and more effective. Staff were seen wearing protective aprons during food handling and aprons are now colour coded to ensure the risk of cross contamination is reduced. This ensures that aprons used for protection during the provision of personal care tasks are not also used in the kitchen during food handling tasks. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 The performance outcomes for staffing are mixed ranging between good, adequate and poor for rota management. However practice is generally judged to be adequate given that actual practice does not unduly result in negative outcomes for service users. EVIDENCE: Staff who were involved in the process of inspection presented as interested, motivated and committed. Where there have been previous concerns about the suitability of staff, the management response has been appropriate. There were no obvious concerns at this inspection about staffing levels which were appropriate during the inspection. The home is carrying three staff vacancies but this is in hand and vacant shifts are covered by agency staff. Communication between the home and the agency is regular and monthly meetings between them are well evidenced. This is a new and positive initiative. Rotas however were found to be poorly managed. Agency and casual staff on duty on the day of inspection were not included on the rota and there wasn’t a clear system in place to ensure that vacant shifts were identified and covered on the rota ensuring that the rota remains an accurate document of staffing arrangements. There was no concern that staffing levels were being mismanaged as amendments were documented in the office diary but this is not sufficient and provides the potential for error. There have in fact been previous errors where changes to staffing have not been reported to the 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 22 manager and subsequent occasions where staffing levels have not been maintained. Robust management of the rota will reduce this risk. The inaccuracies within the rota therefore made it difficult to fully assess staffing levels on this occasion. The previous requirement in respect of staffing levels will remain and will continue to be assessed until systems can better evidence staffing levels. Recruitment records for a new staff member were inspected and all aspects of recruitment practice were found to be good providing good protection for service users. Although systems have improved in relation to ensuring that appropriate checks are in place for agency staff used, this was not the case in respect of checks sampled for one agency staff member whose history was inspected as a result of her also not having been included on the staff rota. No documentation was available to demonstrate that appropriate checks had been carried out and further safeguards agreed between the Manager and agency had also failed. Appropriate action was taken upon discovering this during inspection and the situation was made safe. Subsequent to inspection it was confirmed that checks had been appropriately carried out but these were not available as required. Systems to manage staff training are good. Staff training matrices are updated monthly and it is clear from these when staff have attended courses and when refresher courses are due. There has been a recent innovation where a training action plan has been introduced to ensure that staff teams achieve and maintain training targets of 80 . Training records indicate that staff have undertaken a good level of appropriate training. The main concern is in relation to induction training. Evidence has not be provided that staff are undertaking LDAF induction and there is evidence that because of the induction system used, new staff are not being inducted to the required standard within the required time scale of 6 weeks. One new staff member for example whose training was assessed is undertaking an induction training programme but by the date of inspection on 14 August has not completed this two months after commencing in employment. Fifty percent of the staff group hold NVQ qualifications to the required minimum level which meets the national target and is positive. Records indicated that a new staff member may have received 3 supervisions with the Manager in the two months since commencing employment. Evidence was not available to fully support this and ways of improving this were discussed with the manager. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The management of the home is good with their being more strengths than weaknesses. Where weaknesses are identified through inspection, self audit, complaints or allegations these are responded to appropriately. Good progress is being made to meeting regulatory requirements. EVIDENCE: The Manager remains motivated and keen to improve standards where required. Her ability to do this is demonstrated by the reduction in outstanding requirements following this inspection. She continues to work cooperatively with CSCI. She is qualified to the required national standard. Registration certificates are displayed but do no accurately reflect the categories of service users accommodated. The Registered Manager must ensure that action is taken to redress this as to accommodate service users out of category is illegal. Regulation 26 visits are undertaken by the General Manager and indicate that staff feel supported. Communication between staff and the manager is well documented in monthly staff meetings. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 24 There have been no changes to quality assurance systems since the last inspection which were then judged as good. Neither the Manager nor Provider has undertaken further self-audits. The Managers quality assurance audit is now due and the provider’s full audit of service quality is due in 2007. An improvement in safety was noted at this inspection. Risk assessments are full and complete, hazardous chemicals are all stored away from service users, the medication cabinet was well secured at all times, steps have been taken to improve medication practice, infection control has improved and service documents were up to date ensuring that the safety of equipment within the home is maximised. Areas identified for improvement include water bacteriological risk assessments and ongoing action including a risk assessment for kitchen water temperatures, COSHH assessments (data sheets only were held.) and fridge and freezer temperatures. The Manager immediately sought advice from the Environmental Health Department about COSHH assessments and addressed this prior to the writing of this report so a requirement has not been made for improvement. Fridge and freezer temperatures are regularly recorded as none compliant and the staff members recording this have taken no action. The freezer temperature is recorded at times as reading minus 14, minus 16 and minus 10 which if accurate is too warm and risks service users ill health through food poisoning. Fridge temperatures have also attained ten degrees again too warm and illegal. Staff must be supported to understand safe temperature ranges and their obligation in the event of temperature none compliance. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 Standard No Score 1 2 2 1 3 X 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 3 X 3 X X 2 X 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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 YA1 Regulation 4 Requirement The homes categories of registration require review in consultation with the Commission for Social care Inspection. (Application for miner variation required) The home’s Statement of Purpose must reflect the categories that the home is registered for. Not met at this inspection, August 2006 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) At this August 2006 inspection new service user due to be admitted 2 days later – CCA not obtained. Timescale for action 30/09/06 2. YA1 4 16/08/06 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 27 Not met at this inspection, August 2006 3. YA5 5(b)13(6) The provider must review the 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 Not met at this inspection, August 2006 4. YA6 15,sch3(m) The manager must ensure: Appropriate care plans are produced (At August 2006 to include improvements in nutritional / dietary guidance) Requirement first made December 2004. Not met at this inspection, August 2006 The Manager must ensure that decisions made by others on behalf of service users on a day-to-day basis are accounted for i.e. are documented. New Requirement at August 2006. Families and stakeholders must be provided with access to the homes policy on confidentiality when updated. Requirement first made 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 28 30/11/06 30/09/06 5 YA7 12(2) 30/09/06 6. YA10 17(1)(b) 31/10/06 March 2004 Not met at this inspection, August 2006 7 YA20 13(2) Prescribed medications / supplements must only be discontinued upon the advice of a medical practitioner (eg the prescriber). The advice must be recorded. Not met at this inspection, August 2006 A separate and robust policy and procedure on Whistle blowing must be developed. (New Requirement at August 2006 to seek advice of Local Adult protection Coordinator in respect of sufficiency of Whistle Blowing policy) 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 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- no change Requirements first made March 2005 and not met at this inspection August 2006 9. YA29 23(1)(a)23(2) A loop system must be 30/09/06 provided in communal areas of DS0000037211.V294272.R01.S.doc Version 5.1 Page 29 15/08/06 8. YA23 13(6) 30/09/06 20 - 32 Horton Street the home. (On waiting list) At inspection August 2006 loop system believes to be inappropriate. This must be discussed at service users impending multi disciplinary review Requirement first made December 2003. Not met at this inspection, August 2006 Staffing levels must be maintained at all times. New requirement at June 2005. This was difficult to assess at August 2006 due to poorly managed rotas which were inaccurate. This will therefore remain as a requirement. 11 YA33 9 The Registered Provider must review the organisational structure of the care home ensuring that: Steps are taken to ensure that at all times suitably competent and experienced persons are working at the care home to ensure effective and efficient: • • • • • Uninterrupted work with individuals Organisation Day to day running of the home Management of emergencies Supervision of staff (NMS 36) 31/10/06 10. YA33 18 15/08/06 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 30 The provider must confirm in writing to CSCI by the date set how this will be achieved. New Requirement at August 2006. The manager must ensure that 15/08/06 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 See new Immediate requirement below issued at this inspection To make the situation safe until checks can be verified and to confirm action taken in writing to CSCI by 15 August 2006. To take steps to ensure that all recruitment checks as required by regulation are available on the premises for all agency staff used to protect service users prior to the use of any agency staff at all times. To confirm action taken to CSCI in writing to ensure future improvement to safeguard service users by 16 August 2006. To confirm in writing with evidence to CSCI by 15 August 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 31 12. YA34 19 2006 recruitment checks available and held by the agency for the staff member identified in the immediate requirement letter. New Immediate Requirement issued at this inspection August 06 re recruitment of agency staff. 13. 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. 14. YA35 18 All staff must be provided with COSHH training. This must be completed by the date set. New Requirement at November 2005. At August 2006 3 staff plus new starters remain without this training. Not met at this inspection, August 2006 15 YA41 17(2) Sch 4 (7) The duty roster must accurately represent all persons working at the care home and must be an accurate record of whether the roster was actually worked. New Requirement at this inspection August 2006. Copies of bacteriological certificates must be provided to the Commission for Social DS0000037211.V294272.R01.S.doc 15/08/06 15/08/06 18/08/06 16. YA42 23 30/09/06 20 - 32 Horton Street Version 5.1 Page 32 care Inspection Requirement first made March 2005 and not met at this inspection August 2006 17. YA42 23 (4)(iii) An emergency plan for the home must be developed. New Requirement at November 2005. Not met at this inspection, August 2006 The Registered Manager must take steps to ensure that food is stored at the correct temperature at all times. Staff must be supported to understand safe temperature ranges and to know what action to take in the event of temperature none compliance New Requirement at August 2006. 15/08/06 18 YA42 13(3)(4) 16(2)(G) 16/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA36 Good Practice Recommendations The Registered Manager should review current systems to better evidence the provision of supervision to staff. 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 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: 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 20 - 32 Horton Street DS0000037211.V294272.R01.S.doc Version 5.1 Page 34 - 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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