Inspection on 23/06/05 for 20 - 32 Horton Street

This inspection was carried out on 23rd June 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 33 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 10/11/05

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 23rd June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Horton Street Address West Bromwich, West Midlands, B70 7SG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 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 E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th March 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 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 E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector conducted this unannounced Inspection. The inspection began at 8.45a.m and concluded at 5.30 p.m. The plan for the inspection was to assess those core standards not assessed at the previous inspection. This included care planning and decision making, social activity including opportunities to access the community, family links, routines, personal and healthcare and medication. Recruitment was reassessed following concerns identified at the previous inspection. Service users living at Horton Street are deaf blind with severe learning disabilities. The Inspector was therefore unable to verbally seek their views but spent time with service users observing breakfast, staff interaction and preparations to go out on a day trip. The Inspector also had the opportunity to speak to staff and a visiting support member of staff from head office. The manager who had planned to be away from the home for the day attending meetings returned on the arrival of the Inspector to support the inspection. What the service does well: The Inspector asked a visiting professional who is employed by the provider to define what the home does well. The response was: ‘Accessing the community is a real strength as well as the dedication of the staff to the people who live here. Staff are very dedicated and hard working. There is a strong sense of a person centred approach here and the diversity of service users is managed well. Staff interaction is very good. The manager’s presence is very much felt at Horton Street. She is always there’. The visitor complimented how the manager and staff at Horton Street had managed to successfully evolve from being a service (prior to the move to Horton Street) that was insular with all services needed on site to a highly community integrated service that all service users resident there are benefiting from. The service also positively engages in the inspection / regulation process and responds well to suggestions made for improvement. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: It was disappointing that a concern which was arising at the time of the last inspection where damp and fungal growth were beginning to be in evidence was not more quickly resolved by the Housing Association responsible for maintaining the building. This has not created in some areas of the premises a pleasant environment for service users to live in and has compromised their health and safety. The new care planning system implemented for health must now be extended to all other areas of care to ensure that there is sufficient guidance for staff to meet all areas of service users assessed needs. Some aspects of medication practice have been identified for improvement. There are a number of long outstanding previous requirements which require corporate attention e.g. the development of named policies and procedures. A quicker response and compliance with timescales set would improve the performance of the home and reduce the number of outstanding requirements. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 7 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 E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 5 Prospective service users to the home can be reassured that the home has satisfactory assessment processes to ensure that they are appropriately offered a place at the home. The contract issued to service users upon admission however does not satisfactorily support service users. EVIDENCE: Service users living at Horton Street are a long term and established group. There have been no new admissions to the home. The needs assessment carried out by the home for a service user was assessed. It contained most of the required areas with the exception of assessment and management of risk, adequate income, cultural and faith needs and family carers interest and needs. Each service user has a care plan that is still in the process of being converted to a new format. Health to date has been incorporated into the new format, as this was a priority area for improvement. It remains for all other areas of care planning to be up dated and improved based upon needs assessment. There was evidence of assessment input from an incontinence nurse, occupational therapist, speech and language therapist and behaviour support therapists although, as there have been no new admissions, these professional have been involved for individuals over a period of time rather than at the point of admission. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 10 Service users contracts of residence were assessed and there are a number of omissions (6). This is a long term unmet previous requirement. The existing contract must be reviewed against the requirement of Standard 5.2 and omitted areas must be included. Existing contracts are not in an accessible format and have not been signed by service users, friends, family or supporters. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 Care planning is partly improved with health needs now better recorded and managed. This improvement must now be extended to all other assessed needs. Day to day decisions made by service users were seen to be respected, with assistance given as necessary. EVIDENCE: Each service user has an individual plan, which is partly improved with health planned for in an improved format. The plans include how current needs will be met including planned interventions, therapeutic programmes, communication and language and aids and equipment. Communication advice on one care plan is to finger spell names on to the service user’s hand, speaking name close to the ear allowing the service user to feel the communicator’s face. Further advice in the communication care plan includes how to sign ‘toilet’ as a question to the service user and suggests the provision of a toilet symbol, an object of reference. Risk assessments are in place, which outline reasons for any restrictions made in the service users best interests. The care plan for the service user case tracked has due regard for gender sensitive care. The care plan contains good guidance for staff with respect to communication strategies. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 12 Staff were observed to respect service users decisions which are indicated and understood largely through gesture and behaviour. A vocal service user asked a staff member for a drink. The staff member asked if he wanted a hot or cold drink. The staff member then asked him if he would like tea or coffee tea suggesting that he accompany her into the kitchen to indicate his choice, which he did. A new behaviour support programme emphasises working at the service users pace and according to service users preferred routines. This and discussion showed a developed understanding of the causes of behaviour that challenges and the manager was excited to report that the newly refined approach with the service user had lead to a reduction in behaviours that limit opportunities available to the service user. Work is ongoing with a service user to help and develop his decision-making using recognised models of Communication (PECS). Risk assessments are in place for individual service users, which account for any restrictions or limitations, which in the service users best interest, may provide restrictions. Risk assessments for the service user case tracked include use of a swimming pool, use of public transport, community activities, use of vehicles and environmental risk management including fire, electricity and bathing. Restrictions appertaining to mail and key management are recorded. Voting is not, and this should be addressed. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16, 17. All standards assessed are judged as fully met. Service users are provided with full and varied activities in accordance with their interests both within the home environment and in the community. The preferred lifestyle of each service user is respected and adhered to. EVIDENCE: The manager has developed some very good systems to ensure that activity is provided for each individual service user according to their assessed need and preference. Activities are scheduled weekly in advance for each service user with activities planned for both the morning and the afternoon. Staff have to record the actual activity against the scheduled activity and have to account for why the scheduled activity did not take place. There is some correlation between activities scheduled and those that actually take place. Staff are not always completing the form as intended meaning that it is not possible as intended to use the information to quality assure why scheduled activities are not taking place. For example in the comment section designed for staff to account for any deviation from the plan they have entered ‘good session’. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 14 However there is a high level of activity and many of the actual activities for the service user case tracked for the week beginning 6th June 2005 complied with her recorded preferences. In this one week she went to West Bromwich shopping, undertook domestic skills as planned, did an in house music activity twice, enjoyed the garden as planned, attended a hospital appointment and went to the Clent Hills. The planned activity that she did not get to do was to go swimming twice. Swimming is a recorded hobby and no explanation was afforded for this being cancelled twice in one week. Records for a further recent week however show that she did go swimming, had a massage, went to the park, enjoyed a bubble bath, went for a walk around the block, had a foot spa and had a hair appointment in the community. The manager is keen to maintain a neighbourly relationship with the home’s immediate neighbours. Concerns identified by one neighbour appear to have resolved. Following the inspection but prior to writing this report the manager informed the Commission for Social Care Inspection that noise levels from one service user in the garden has been commented upon by a second neighbour. The manager has previously contacted the Environmental Health Department for advice in respect of this and they have said that if required they will return to measure noise output. The manager intends to arrange to meet with neighbours to ask for their support and to explain steps that are being taken by the home to limit any disruption. The manager must remember to record this as a complaint. The home has its own mini bus to enable access to the community. A requirement has been made to review the funding for this because 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. Service users are not politically active and any restriction appertaining to this must be accounted for in the plan of care. Staff time is provided flexibly to best meet the needs of service users and the staff composition reflects the local and service user community. Service users went out on an organised trip during the day of inspection to an activity centre in the community. At the beginning of the week they had been on a canal trip. The manager will establish with the organising company and the home’s insurers who is responsible for undertaking risk assessments when trips such as these are commissioned out but partly staffed by the home’s own staff team. Family birthdays are logged so that service users can be prompted to remember significant dates. Family contact details are recorded too. Contact needs must however be formally assessed for each service user, planned for and monitored. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 15 In terms of outcomes for service users the home’s practice in relation to Standard 16 is good with an emphasis in records and practice on working around service users individual routines to promote dignity, choice, contentment and subsequently positive behaviours. Service users preferred mode of address, responsibility for housekeeping tasks must be incorporated into plans of care. Furthermore rules on smoking, alcohol and drugs are not included within the terms and conditions of residency contract. Performance against each element of Standard 17,’meals and mealtimes’ is good with each element met. Service users have been referred for dietician support. Weights are being taken and recorded regularly but weights are difficult to compare as some are taken with and some without clothes. Weight records were not complete for one service user case tracked. Furthermore needs in respect of healthy weight and nutrition would be better assessed if there was a record of each service user’s ideal weight range. This information can be obtained from the dietician. Lunch was observed to be a quiet and calm occasion. Staff were able to explain assessed needs for eating for the service user case tracked. This accorded with the written care plan. Whilst there are some administrative tasks to improve in relation to some of these Standards they have been judged as fully met as the outcomes for service users are good and provide for a good quality of life. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Horton Street is providing a good level of service in terms of personal and healthcare support with minor areas identified for improvement. Improvements in some areas of medication management must now be the priority area for improvement to ensure the continued health and safety of service users. EVIDENCE: Standard 18 which covers all aspects of personal care and support is fully met. Records to support practice are comprehensive addressing gender appropriate personal care, retiring and rising times, personal care routines and preferences. More technical aids and equipment have been provided since the last inspection to meet the personal needs of one service user whose posture care has been assessed. It was pleasing to see feminine hygiene and grooming e.g. hair removal addressed for clients promoting the dignity and self esteem of service users. Records show that a service user who uses incontinence pads is supported to use the toilet promoting independence and dignity but this practice is not included in a plan of care which under the heading continence, only refers to the use of pads. For the service user case tracked by the Inspector there was evidence of support to access the dentist, optician, audiologist, chiropodist and to attend outpatient and other appointments. The assessed needs of the service user Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 17 case tracked refer to the need to syringe or suction ears but there was no evidence that this need has been met. Diabetes care management has also improved and training in diabetes management had been booked for 27 June 2005. Changes in health are responded to appropriately and minimum annual health checks are now included in plans of care which is an improvement since the last inspection. Care plans have been improved with respect to Health as this has been the aspect of care prioritised for improvement. Planning is now based upon an updated needs assessment which is addressed by a specific goal with a monitoring and evaluation system. The manager must ensure that the evaluation fully reflects the set goal. A staff member told the Inspector that the new health log is a much better system. The Inspector observed the whole staff team at handover meet. A detailed and structured handover was given with all staff participating and describing the shift for each service user in respect of personal care received, meals eaten, mood and there was an emphasis led by the manager on the need to reapply sun cream every hour and a half to protect service users immediate ad long term health. Medication is listed in the plan of care and tallied with the Medication Administration record for the service user case tracked. Medication stocks need addressing. The manager recognised that stored medication is stockpiling. This is both a waste of resources and increases risk. In some cases medication that is still being prescribed was not in stock as the manager said it had not been used for 12 months. Prescribed medication must be administered or reviewed with a medical practitioner who must be the one to make the decision to discontinue use. This decision must then be recorded. Ear drops were being used that had been opened in April 2005 and exceeded the expiry date. One care plan includes the use of E45 cream which was not on the medication administration record. The manager stated that as a decision has been made to discontinue the use of homely remedies, this is no longer being used but the care plan had not been updated. The supporting pharmacist has agrees that it is acceptable to store medication in a medication cupboard in the bathroom as long as temperatures are not exceeded. The manager must therefore ensure that the temperature of the room is taken regularly and recorded. The medication policy is being corporately reviewed but was not available at the time of inspection. Medication administration records were seen and were appropriately maintained. All other aspects of medication practice were satisfactory. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These Standards were not assessed. These Standards were not assessed. EVIDENCE: These Standards were not assessed. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 30 The company that maintains the premises had not responded sufficiently to reported water leaks within the building to ensure the health, safety and comfort of service users. EVIDENCE: Whilst it was not planned to assess environmental standards at this inspection one issue arose during the course of the inspection that required attention. At the previous inspection the Manager had mentioned evidence of fungal growth in the corridor upstairs and bathroom. The situation had clearly deteriorated at this inspection. There were heavy water leak marks downstairs in two main places and water had collected on the shelf of a built in cupboard on the ground floor wetting an electric extension lead. Upstairs there was fungal growth in the bathroom, 2 ensuite showers and the corridor. ‘Mushrooms’ were in evidence and parts of walls were black with a strong smell of damp, which were neither attractive, pleasant nor healthy. The Inspector and manager expressed concern about the risk to the electrics, the risk of fire and the risk of the ceiling coming in. A surveyor had visited to assess the situation on 9th June 2005, two weeks prior to the inspection but there had been no further action taken and the manager had not been notified as to the cause, Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 20 level of risk or work needed. The Inspector asked for immediate action to be taken during the course of the inspection and as a result a surveyor, electrician and plumber visited the site during the same day. The source of the problem was identified and the manager was told there was no risk. The manager requested that someone qualified to do so formally identify the level of risk. It appeared as though in order for remedial works to be carried out service users and staff would have to vacate over night. The manager did not perceive this as a problem but as an opportunity to book to ‘go away for the weekend / overnight’. The Inspector has not at the time of writing this report received an update concerning the situation and this is required. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The home’s recruitment practice has improved and previous requirements have been met. Service users are now better protected. EVIDENCE: Immediate requirements were issued at the previous inspection in respect of insufficient recruitment practice. Action has been appropriately taken to address all areas of omission identified. No new staff have been recruited since the last inspection. It was noted that written confirmation about checks undertaken by the supplying agency for agency staff supplied does not include reference to POVA checks but only makes reference to ‘past, current or impending convictions’. The manager telephoned the agency during the inspection to clarify this and was assured that POVA checks are undertaken but had not been included in the written details provided. The manager has requested that this additional information be provided in writing to her. This was agreed. Staffing levels were not assessed but on arrival at the inspection the staffing complement was one staff member down. There were 4 staff on duty instead of 5 at the peak period of the day between 7.00a.m and 10.00a.m. This was because a staff member had phoned in sick the night before and the message had not been passed on so that cover could be arranged. This is not acceptable. Staffing levels will be closely assessed at the next inspection. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 22 A visiting NVQ assessor to the home confirmed to the Inspector that 7 out of 15 staff not including the manager have a minimum of NVQ level 2. Four other staff are currently working towards their NVQ qualification with the remaining 4 not having started yet as they are completing their probationary period for 6 months first. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not Assessed These Standards were not assessed. EVIDENCE: These Standards were not assessed. Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 1 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Horton Street Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, Requirement The home’s Statement of Purpose must include/amend the following; The range of ages, sex, and needs that the home is intended to meet. The home must not admit service users funded by Local Authorities prior to receipt of a completed Community Care Assessment 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) 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 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 26 Timescale for action NOT MET No Progress 31.8.05 Upon Next Admission (No new admission) NOT MET 31.8.05 2. YA2 14 3. YA5 5(b) 4. YA5, 7, 13 5(b) 13(6) 30.9.05 5. YA6 15,sch3( m) 6. YA7 12(2) 7. YA9 13(4) 8. YA9 13(4) 13(7) 9. YA10 17(1)(b) The manager must ensure: · Appropriate care plans are produced · A written record is kept of reviews of care plans Requirement first made December 2004 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.) The manager must undertake 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). 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. 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) 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 PART MET 30.9.05 PART MET 31.8.05 NOT MET 31.7.05 PART MET 31.7.05 NOT MET 30.9.05 NOT MET 30.9.05 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 27 10. Ya13 15, 12(2)(3) 12 11. YA15 Any restrictions appertaining to 30.9.05 voting must be accounted for in the plan of care. New Requirement June 2005 Contact needs with friends and 30.9.05 family must be formally assessed for each service user, planned for and monitored. New Requirement at June 2005 All service users to have a comprehensive nutritional assessment that is reviewed regularly and appropriate action taken Format obtained but not completed Requirement first made December 2004. 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 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 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) A multi-disciplinary decision to administer medication covertly must be obtained and recorded NOT MET 31.7.05 12. YA17 12 13. YA19 12 NOT MET 31.7.05 14. YA19 12, 13 31.7.05 15. YA20 13(2) Not Met 31.8.05 16. YA20 13(2)(4) NOT MET 31.8.05 Page 28 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 17. YA20 13(2) with signatures where possible. (Manager said this discussed at review 13.6.05 – notes not available at inspection June 05) The manager must ensure: · A covert medication policy must be produced Requirement first made December 2004. 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. The temperature of the bathroom where medication is stored must be regularly taken and recorded and appropriate action taken if found to exceed the recommended range. New Requirements at June 2005 All complaints must be logged in the record of complaints book: The complaint received as part of the homes own satisfaction questionnaire poll must be recorded appropriately in the home’s complaint log. Guidance must be available in an appropriate format for members of the public detailing how to make a complaint and what to expect following making a complaint including timescales and the details of CSCI. Requirements first made March 2005. Not Met 31.8.05 18. YA 20 13(2) 31.7.05 23.6.05 23.6.05 30.6.05 19. YA22 22 NOT MET (complaint book not located) 31.7.05 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 29 20. YA22 22 21. YA22 24 22. YA23 13(6) 23. YA23 13(6) All complaints/comments must be recorded (complaint from relative not included) (At June 05 Complaints book not located) The complaints procedure must be displayed in the entrance hall. The Concerns and Complaints policy must be updated to reflect recent legislation e.g. The Care Standards Act and must include the contact details for the Commission for Social Care Inspection. A separate and robust policy and procedure on Whistle blowing must be developed. 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 All allegations and actions taken must be reported to the Commission for Social Care Inspection – NO RECENT INCIDENTS Requirement first made March 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 NOT MET 31.7.05 Part met no progress 30.9.05 NOT MET 30.9.05 PART MET 31.7.05 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 30 24. Ya24 23 protocol not in place) Requirement first made March 2005. Water leaks throughout the building must be satisfactorily resolved without delay. The manager must confirm in writing to the Commission for Social Care Inspection actions taken in respect of water leaks throughout the premises and the outcome. New Requirement at June 2005 A loop system must be provided in communal areas of the home. (On waiting list) Requirement first made December 2003 Disposable aprons must be available in the laundry for use at all times. A ‘Now Wash Your Hands’ Sign must be put on wall in laundry. Staff working in the kitchen must wear an apron at all times. Requirement first made March 2005. The manager must seek the advice of the infection control nurse about: · The storage of medication cabinet in bathroom. · The sufficiency of part tiling in the laundry. (At June 05 advised in absence of Infection Control Nurse to contact Environmental Health) Requirement first made March 2005 The home must develop an Infection Control policy. Requirement first made March 2005. The manager must contact the Infection Control nurse in respect of the previous requirement to reduce the risk of 30.6.05 31.7.05 25. YA29 23(1)(a) 23(2) PART MET No Progress 31.8.05 NOT MET 30.6.05 26. YA30 13(3) 27. YA30 13(3) NOT MET 31.8.05 28. YA30 13(3) NOT MET 30.9.05 NOT MET 31.8.05 29. YA30 13(3) Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 31 30. 31. YA33 YA34 18 19 32. YA35 23(4)(d) cross contamination in the laundry (advice re risk assessment / measures) including the means of transporting and storing soiled linen. In absence of Infection Control Nurse advised to seek information from Environmental Health Requirement first made December 2004. Staffing levels must be maintained at all times. New requirement at June 2005. 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. Fire training must be included on the home’s training matrix. Requirement first made December 2004. 23.6.05 30.6.05 33. YA40 13(6) 34. YA42 23 The manager must obtain clarification in writing as to whether the homes policy on Physical Intervention meets Department of Health Guidelines. Requirement first made March 2004 NOT MET Copies of bacteriological certificates must be provided to 31.7.05 the Commission for Social care Inspection. Copies of routine In house water temperature check records must be provided to the Commission for Social care Inspection. (At June 05 temps of basins in bedrooms and kitchen not being taken) Version 1.30 PART MET(added put part complete) 31.7.05 Not met 31.8.05 Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Page 32 35. YA42 23(4) 36. YA42 23(4)(d) N’s wardrobe must be attached securely to the wall. Requirements first made March 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 JUNE 05 Requirement first made at March 2005 Fire Training for all staff must be provided twice a year. (All staff done Feb / March 05 more planned for July 05) Prior to change Part Met – Feb 05 – Feb 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 None Good Practice Recommendations Horton Street E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 Page 33 Commission for Social Care Inspection Mucklow Office Park West Point, Mucklow Hill Halesowen B62 8BR 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 E55 S37211 Horton Street V232889 230605 Stg4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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