CARE HOME ADULTS 18-65
23 Barncroft Street Hill Top West Bromwich West Midlands B70 0QJ Lead Inspector
Deborah Sharman Key Unannounced Inspection 22nd August 2006 09:30 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 23 Barncroft Street Address Hill Top West Bromwich West Midlands B70 0QJ 0121 556 8809 0121 556 8809 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) Milbury Care Services Limited Mrs Hayley Whitehouse Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 16th December 2005 Brief Description of the Service: 23 Barncroft Street is an adapted bungalow property, which is owned and managed by the Milbury organisation. The home is situated in the Hilltop area of West Bromwich, which is easily accessible and is close to nearby public transport routes. Local shops and amenities are also available. The accommodation consists of four single occupancy bedrooms, kitchen, lounge/dining area, and bathroom and toilet facilities. The home offers a small enclosed rear garden/patio and off road parking to the front of the property. A range of services are on offer and include social and recreational pursuits, an open visiting policy, access to visiting healthcare professionals, a varied menu, and in house activities such as aromatherapy, sensory sessions, and games. Service users are offered 24-hour personal care and support, including two wakeful night staff on duty. All staff aim to enable service users to live an ordinary life in the community. The weekly fee currently ranges from £935.65 to £1290.00 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced meaning that nobody associated with the home received prior notification and were therefore unable to prepare. One Inspector conducted the inspection which started at 9.30am and finished at 7.30pm. The home’s Registered Manager and Senior staff supported the inspection. The aim of the inspection was to assess as a minimum all key National Minimum Standards including progress towards meeting requirements issued for improvement at previous inspections. A range of methods were used to collate evidence to judge the homes performance. The Manager, senior and junior staff were interviewed, documents were assessed including records that evidence care provided to a service user selected for case tracking. Service users went out for part of the inspection day but the Inspector was able to talk to one service user about the home. Other service users are none vocal but appeared happy and contented throughout the day. The Inspector also toured the premises and observed a staff member administering medication. Information provided to CSCI prior to inspection was also followed up during the course of the inspection. This was a very encouraging inspection. Whilst there were a few significant omissions identified, most of the previous requirements identified by CSCI for improvement have been met demonstrating an improvement in systems, management and standards within a short time period. The Manager and staff have worked hard to achieve this demonstrating a commitment to complying with the National Minimum Standards. With the addition of new requirements arising from this inspection the number of requirements has reduced from a total of 23 to 12. What the service does well:
The home is working well towards meeting the National Minimum Standards and is demonstrating a commitment to improvement. The home is well managed with the manager providing good direction and leadership for the home. 23 Barncroft is a small domestic style bungalow discreetly located within the community. There continues to be a happy welcoming and calm atmosphere and staff spoken to report being happy working at the home commenting that the team is a happy one. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 6 Good systems are in place to assess and introduce new service users to the home. This assures service users that they will only be admitted to the home if the Manager is confident that the home can meet their assessed needs. The home is also judged to manage complaints and protection well and to also provide a good environment and good systems to support effective staffing. Such examples assure service users that they will benefit from a well managed home. What has improved since the last inspection?
There have been a significant number of improvements made within a short time period. Most of the outstanding requirements for improvement have been deleted from this report as the manager who since the last inspection has become Registered with the Commission for Social care Inspection has successfully demonstrated compliance. Admissions processes have improved. The Manager demonstrates a good knowledge of how a new service user should be admitted to the home and potential limitations that would prevent admission to the home. Systems have been put in place to better structure and evaluate activities available to service users. Similarly new systems have been introduced to ensure that changes in service users health are recognised and responded to. Consequently the provision of health services to service users have been better evidenced at this inspection with there being a rolling programme of health screening now provided. Accredited medication training has been provided to staff better ensuring that they are equipped to more safely administer medication to service users. Adult protection policies have been improved to provide better guidance for managers and staff in the event of there being an incident that compromises the safety of a vulnerable adult. Vacant staff posts have been recruited to increasing staffing hours available and ensuring greater continuity of care to service users as there is less reliance on agency staff. Measures have been taken to promote service user safety e.g. by the provision of fire safety training, improvement in cold food storage temperatures and hot water temperatures limiting the risk of food born illness and scalding from hot water. Fifty percent of staff are qualified to minimum levels. This complies with current national targets and assures service users they will be cared for by qualified staff. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 7 Significantly steps have been taken to improve the living environment for service users enjoyment. Communal areas, which were previously worn and tired with ripped wallpaper, have been decorated and this has considerably improved the environment, which is now pleasant and calming. Carpets have successfully been cleaned throughout the property and new curtains provided in the lounge and dining room. A service user recently admitted to the home reported that s/he likes the home, likes his / her bedroom and likes the staff. What they could do better:
Activities have improved and there is evidence that service users have access to the community and are supported to undertake some of their hobbies and interests. This needs to be developed further to ensure that service users individual key interests are facilitated with greater regularity in accordance with person centred care. Systems have been implemented to audit medication records and practice. Training to staff in the administration of medication has also improved. It is disappointing therefore to both the manager, senior staff and the Inspector that significant concerns relating to the administration of ear drops were not identified as part of this process. Practice was poor in relation to the administration of these eardrops. Written direction for their administration was poor and contradictory and directions had not been adhered to, with there being evidence of both over and under administration. The result of this was poor health outcomes for this service user and an unnecessary waste of NHS resources and time. There was some evidence that staff understanding of behaviour management needs to improve. The Manager had already identified and responded to this identified need however and a psychologist had been booked to support staff during the week of this inspection. The use of bed rails need to be better managed. Risk assessments are not in place to account for their use. If bed rails are used and not needed they can unnecessarily limit the freedoms of service users and are potential restraints. The need for bedrails in one case could not be sufficiently evidenced at this inspection. Risk assessments had been put in place to reduce risk during their use but were not sufficiently developed. Gaps between the mattress and rail where there is potential for limb entrapment had not been addressed and bumpers were not in use. The Manager had sought the advice of the Occupational Therapist about this but action had not been taken to address the safety concerns sufficiently quickly. Action was taken urgently however during the course of the inspection. The provisions of ramps to comply with the homes own Fire risk assessment have not been provided.
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 8 The manager has taken steps to try to improve quality assurance systems whilst waiting for corporate systems and has attempted to seek feedback from a service user about the service provided by the home. Staff’s supporting service users to complete such questionnaires however have not demonstrated sufficient impartiality to ensure the validity of outcomes and ways to achieve greater impartiality should be sought. Nutritional risk assessments have been undertaken since the last inspection but the outcomes of these have not been accurately represented in diet / nutrition care plans. This does not ensure that identified need is met. Similarly inaccuracies and lack of negotiated detail in care plans for family contact compromise ensuring service users needs are identified and met and these remain as requirements. 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. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 The overall judgement for this group of Standards is good. Service users can be assured that systems are in place to ensure that service users will only be admitted to the home if the manager is confident that the home can meet their identified needs. Service users are offered sufficient opportunity to decide if they wish to live at Barncroft prior to moving in. EVIDENCE: All previous requirements relating to the admission of a new service user have been deleted as met. The most recently admitted service user to the home has a care plan based upon assessed need. In addition the manager had written two letters confirming that following assessment the home could meet the service users identified needs. There was excellent and detailed records available to evidence that the service user had had several visits to the home prior to admission and improved copies of contracts of residency between the home and the service user were available and had been signed by the service user. Full and appropriate risk assessments had been carried out prior to the service users admission to the home. The home currently has a service user vacancy and the Manager is considering a referral for this vacancy. The Manager has obtained copies of assessments undertaken by the placing Social Worker and there was some evidence that the manager has started to undertake her own assessment of the service users needs. The manager is well aware of her role and responsibilities in the 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 11 admission process and demonstrated an awareness of issues which may limit this proposed service users suitability for the home. Service users have copies of improved service users guides in their bedrooms. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The overall judgement for this group of Standards is adequate. Whilst risk assessments are good and care plans are in place some improvement in care plans and decision-making systems and practice would improve outcomes for service users. EVIDENCE: Care plans are generally adequate with their being more strengths than weaknesses. They need review however to ensure sufficiency in detail and accuracy. Nutrition care plans did not accurately reflect risk identified in nutritional risk assessments and contact arrangements with family have not been reviewed and some are not accurate. None specific statements such as ‘regular’ should be avoided ensuring that time scales are specific and measurable. A person centred care plan has also been recently introduced in addition to the existing care plan. All aspects of the care plan however should be person centred. Health action plans have been introduced too as assessed by Community Nurses, some aspects of this require greater clarity and clarification as the Manager and Senior staff were not aware of some diagnoses included or the ramifications of these.
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 13 Service users involvement in decision making about their own lives is generally good but not entirely consistent, with performance being mixed at times. One service user has an actively involved independent advocate to support her interests and information about advocacy schemes was available in the office. The care plan outlines how the service user makes decisions and also includes areas where the service user can’t make decisions or where the service user requires support to make decisions. Guidelines for managing the service users finances for example are detailed but there was evidence that these had not been complied with where authorisation is required to spend over £100.00 of the service users monies. The service users preferred daily routine is not available in full for staff guidance but preferred rising and retiring times are. Records evidenced that these are flexibly responded to depending upon the wishes of the service user at the time. The Manager must ensure that staff remember to offer options at every opportunity to service users. Incident records indicate that one service user who uses a wheelchair may not have been offered a choice as the service user was ‘put in the lounge’. This had immediately preceded behaviours from the service user who is known to prefer to spend time in the bedroom. The behaviours subsided when the service user was moved to the bedroom. The initial offer of choice may have avoided the need for behaviours. Residents meetings are not held but individual key worker meetings are. Minutes are not available to demonstrate decision-making processes but the Manager had addressed this with senior staff who lead the meetings just prior to inspection. Risk assessments are available in respect of each individual service user. Risk assessments are varied and appropriate in range and had been completed pre and post admission for the service user case tracked. Risk assessments address pressure sore risk, manual handling and transferring risk, pain, challenging behaviour as well as sun burn, use of the hydraulic bed, use of the vehicle, drowning, slips and falls, scolds and burns, public transport, personal care and indoor activities which states 1:1 staffing at all times. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 14 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 overall judgement for this group of Standards is adequate. Service users partake in some not all of their preferred activities and have access to the community. There is evidence of family contact being mostly maintained although this requires review for some service users. Service users enjoy their meals although systems to ensure that nutritional need and health is met must improve. EVIDENCE: Care plans for family contact are not accurate and require review. Systems to evidence contact with family have improved and there is recorded evidence of face to face and telephone contact with families. Service users who are able are asked twice per day if they wish to use the phone and there is evidence of the choices they make being acted upon. The reasons why one service user has limited family contact have not been explored to see if there are ways in which contact can be supported by the home. One service user went out for lunch with a parent unaccompanied by staff during the inspection and had clearly enjoyed this opportunity.
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 15 A pictorial activity planner is now in place, which is broadly adhered to, and systems are in place to monitor any changes made to the plan. It is noted that service users interests that fall within a limited range are more easily met e.g. shopping, videos, meals out, and day trips. Whereas more specific and unusual hobbies such as drama, typing and computer lessons, which are included on the activity, plan are less readily met with their being little evidence of the service user being supported to fulfil these. There is however regular access to the community. Weekends are not included in activity planners and this is therefore less directed. There is evidence of weekend activities and trips taking place during most if not all weekends. Food intake records which correspond to menus for each service user are kept and show the service user case tracked to be provided with alternative meals to others especially at breakfast e.g. egg sandwich instead on cereal. Amounts eaten are recorded which is good practice. Meals appear to be varied although deserts are not sufficiently varied. Deserts provided are all of a similar consistency e.g. yoghurt, mousse, ice cream and varieties of cake. There are few hot and traditional puddings offered. They are aimed at those trying to reduce weight but not all service users are overweight with one service user being identified at increased risk from weight loss. Meal times are flexibly provided. Nutritional risk assessments have been undertaken since the last inspection but increased risk identified has not been responded to appropriately for two service users one who has lost weight and a second service user who has gained weight contrary to need. There is no evidence therefore that nutritional outcomes for service users are improving. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 The overall judgement for this group of Standards is poor. Although the provision of personal care is good and the provision of health care has improved to adequate the significance of some issues identified within medication practice (which is subject to improved monitoring) is poor and potentially puts service users at risk. EVIDENCE: There is good evidence of the provision of regular and appropriate personal care and service users all present as well groomed with their own individual style that reflects their personalities. There is evidence too that service users preferences about how they are moved and transferred are complied with. Staff are aware of service users preferred rising and retiring times and that there is evidence that these are flexibly rather than rigidly adhered to. Technical aids and equipment are available to support the safe moving and transferring of service users. There is a hydraulic bath, wheelchairs and a hoist, all of which have been regularly serviced. Systems to improve health provision to service users have been put in place to ensure the prompt identification and response to pain and other general changes in health status. The service user case tracked has received chiropody, dental and optical screening since admission this year.
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 17 The medication care plan accurately reflects medication regularly prescribed. Medication is well stored and is not overstocked. Medication training has improved and is now accredited training. However whilst observing a staff member administering medication, the dispensed medication was left exposed and unattended in the tot in the service users bedroom whilst the staff member left the room to fetch a drink. The service user was also present in the bedroom and potentially at risk. Upon return the staff member was aware of her error but felt that the presence of the Inspector in the bedroom was a sufficient safeguard. This is not acceptable. The Inspector had not been asked to fulfil this role and lack of communication presents the possibility of error. There was huge lack of clarity in respect of ear treatment being provided to a service user for a build up of earwax. Copies of prescriptions were not available so it was not possible to trace whether Olive oil being used had been prescribed in addition to Cerumol ear drops as the Inspector was informed. The supplying pharmacists advice to improve the manner in which handwritten directions are added to MAR sheets has not been implemented with potentially serious consequences. Handwritten directions on Mars are not sufficiently detailed to guide administration and not signed by 2 staff (although this has started since). The frequency of use is included as written direction but the number of drops to be administered is not. Cerumol eardrops should have been administered twice per day but records show that they were only administered once per day for ten days of a twoweek prescription. There is no empty bottle and no evidence that any was returned to the pharmacist so it is concluded that in the absence of direction regarding the amount to be administered that too much was administered on every single occasion. When the service user returned to the GP wax could not be removed because it was still ‘too hard’. This is unsurprising, as directions for the usage of the drops had not been adhered to. In addition, the later use of Olive oil from 15.6.06 is directed in handwritten form as ‘20mls use twice per day’. As receipt of the product has not been recorded in it is unclear whether 20mls was prescribed in total or whether 20mls is to be administered twice per day. Furthermore records show from 17.6.06 olive oil ‘prescribed’ as twice per day but administered three times per day. There is the potential here for irreparable significant harm to service users if directions were to be unclear for drugs rather than olive oil. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 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 the following standard(s): 22, 23 The overall judgement for this group of Standards is generally good as there are more strengths than weaknesses. Specific isolated incidents that fall below this standard have however been identified that require improvement. The Manager has provided assurance that these areas will be improved for the greater protection of service users interests. EVIDENCE: The home has not received any formal complaints and none have been made to CSCI. Some steps have been taken to improve the complaints procedures which have been simplified for service users with a copy seen to be in service users bedrooms. The written format would not however be suitable and accessible for all service users living at Barncroft. A complaints log is available but there are no recent entries within it. Some constructive comments detailed at length by a family member in response to feedback being sought by the home as part of its quality assurance mechanisms have received a written response from the manager. The home has received a written acknowledgement of thanks from a relative of a service user recently discharged from the home. Written guidance available to the home has improved since the last inspection and no longer provides inaccurate advice in the event of their being an adult protection concern or allegation. Advice about the new national POVA list has not been included in the Adult Protection policy as required but is included in Human Resource policies. The Inspector and Manager agreed that it would not be immediately evident as to where to locate this information. There have been no allegations, staff disciplinaries or dismissals. All staff including new staff have undertaken adult protection training and a staff member interviewed
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 19 demonstrated a good knowledge of what her role and responsibilities would be in the event of becoming aware of adult abuse. Service users do demonstrate some behaviours that can challenge. Full and detailed care plans are in place that recognise triggers for behaviours and guide staff response. It is essential that all staff are supported to understand this fully as one incident record indicated little understanding of how staff can impact upon and exacerbate behaviours. The manager has arranged for a Psychologist to support staff learning. Restraints are not used but the manager must review the need for bedrails to ensure that they are being used appropriately. Service users monies were inspected and records checked balanced against cash in hand held on the premises. Receipts are available and records are detailed and also tallied with monies withdrawn from the bank. It is not however appropriate for a service user to be funding lunch out which is part of the programme of activities. The home is paid to provide lunch and funds other service users lunches out to the value of £4.00. The service user must be reimbursed. Furthermore protocols are in place where authorisation must be obtained for any spending on service users behalf over £100.00. A service user has spent £300.00 on furniture which the Inspector was told she chose to buy over and above the furniture provided by the home, but systems were short circuited and authorisation not obtained due the Inspector was told to time constraints. The Manager must ensure that there is better planning for large expenditure to ensure sufficient time to adhere to processes designed for the protection of both service users financial interests and the protection of staff and the manager. A service user has an active advocate to represent interests independently and the home is committed to this being available for the service user. The manager has a good understanding of in what circumstances an advocate may be required and written literature about advocacy services is available within the home. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 20 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 The overall judgement for this group of Standards is good. Décor and infection control systems have improved and the premises are now homely, clean and hygienic. EVIDENCE: Improvements have been made to the environment since the last inspection. Communal areas have been decorated with the result that the premises are now much more homely. Carpets have been cleaned throughout andnew curtains provided in the lounge and dining areas. The garden has been furnished with gravelled areas and flowers have added colour. Service users bedrooms are all individualised to reflect their interests and preferences. Windows, radiators and wardrobes are safe. Water temperatures throughout the building and within service users bedrooms are safe. One service user said that the bedroom is ‘nice’ and ‘I like it best in my bedroom’. The service user also said that’s/he had everything that s/he needs. S/he compared the home to where ‘s/he was living before and said that s/he likes it best ‘here’. Premises are clean with no malodour. Equipment required is provided – arm rests on the toilet, a commode, hydraulic bath, hoists, wheelchairs and a new dining table has been bought to accommodate a service user who prefers to sit at the dining table in the wheelchairs. It remains for ramps to be provided in
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 21 line with the homes fire risk assessment to ensure safe and quick exit in the event of a fire for service users who are wheelchair users. No areas for improvement were identified in respect of infection control practice. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 22 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, 34, 35, 36 The overall judgement for this group of Standards is good. Staff are motivated, welcoming, recruited safely and are offered regular appropriate training. EVIDENCE: Staff present as interested and motivated, with senior staff coming in to support and learn form the inspection process. A staff member interviewed demonstrated a good value base that places service users rights and interests at the heart of all decisions. A service user spoken to said that s/he liked the staff. The personal file of a new staff member was assessed and recruitment practice is very good with all documentation found to be in place and appropriate to safeguard service users. The only exception was a missing job description and induction to LDAF standard which had not been provided. An induction based upon the TOPSS standards had been provided but not within 6 weeks. It was very pleasing to see that in the first six months of employment this new staff member has been provided with 4 formal and recorded supervision sessions, which is well on target to meeting if not exceeding the national target. There is a rolling programme of training and an up to date team-training matrix to help plan training for both the team and individuals. This shows that all staff have completed Fire Awareness training, Moving and handling training,
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 23 adult protection training (with written confirmation that additional training has been booked with the local authority for the team). Training has also been provided for some staff about autism and epilepsy. Tissue viability training has not been provided. The staff team has attained the national target for numbers of staff that must be qualified to minimum levels in NVQ in care. There are three service users accommodated currently as the home has a vacancy. The home has been fully staffed but one staff member has recently transferred to another home but the loss of 21 hours is offset by the reduction in service user numbers. As a minimum 2 staff are on duty, with 3 – 4 being on duty to support activities. It was pleasing to see the rota accounting for service user appointments and planning extra staff in accordingly. The home has lost its sleeping in night staff member as these hours have been relocated to use during day time peak waking hours. There is one waking night staff on duty at night now. Contingencies in the event of fire at night were considered at the time but must be kept under close review. The fire risk assessment is due for review this month. The Fire officer visited in January 2006 and as a result more magnetic closures have been fitted to include bedroom doors. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 24 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 overall judgement for this group of Standards is very good. Service users benefit from a well run home where action is taken by the Manager to address any omissions identified. EVIDENCE: The manager who is registered with the Commission for Social Care Inspection reported that she has now finished her Registered Managers Award as well as having achieved NVQ 4 in Care and is subsequently qualified to the required national standard to manage a care home. She is however still awaiting certification and should provide copies of these to CSCI as soon as they are available. There was evidence too that she has participated in ongoing other training to update her skills and knowledge. Senior meetings are held monthly prior to staff meetings and there were detailed minutes available to demonstrate that the views of staff are listened to and that the Manager provides direction and leadership. A staff member confirmed that monthly staff meetings are held and that the manager is approachable and provides good direction and leadership adding ‘I’ve learned
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 25 a lot from her’. The Inspector was told that ‘the manager is very hard working and if the manager is hard working then so are the staff. She makes sure that everything is done’ by encouraging everyone and raising things that have not been done at staff meetings. The staff member reported the team to be very friendly working together as a team. Outcomes from this inspection where the home is seen to be moving forward and improving support this. The provider is working on developing corporate quality assurance systems which are not yet complete. In the meantime the Manager has devised her own and sought feedback from a vocal service user supported by a staff member. However whilst the attempt is admirable the outcomes were not wholly representative of the service users view as the staff member supporting the service user to give views had been unable to act impartially. This was evident from the records available. Also systems had not been devised to find ways to elicit the views of none vocal service users. The manager said that she would try to devise a method to enable the views of less vocal service users to be known. The views of service users relatives have also been recently sought. Three out of four responses demonstrated 100 satisfaction. A third response demonstrated some areas of satisfaction but raised a lot of questions which have been responded to in writing by the manager. Most aspects of Standard 42, safe working practices were found to be met with their being few omissions. This provides service users with the assurance that they are living in an environment that is well-managed e.g. electrical, gas, fire detection systems as well as moving and handling equipment are all regularly maintained. First aid equipment is available and accidents are recorded. Risk from hot water and food storage is controlled now too. The manager has identified and taken action to address any shortfalls e.g. first aid training has been booked. . Risk assessments for hazardous chemicals are in place and have been updated however two products were found unattended in the toilet contrary to control measures indicated in the risk assessment. Ramps would provide quicker exit in the event of a fire and the home is contradicting its own risk assessment too through the on going none provision of these. All incidents have been reported to CSCI with updates where appropriate during the inspection year, as is the homes regulatory duty. This demonstrates open and transparent management. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 2 X X 3 X 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement The Manager must ensure that care plans are person centred, cover daily routines, all aspects of personal, social and health care needs and aspirations, are accurate and that required frequencies of care are specific and measurable e.g. ‘monthly’ rather than ‘regular’. New requirement at this inspection August 2006. Risk assessments in place for bedrails must be reviewed and developed to address reasons for use and safety risks during use with safe systems identified for all risks. New Requirement at December 2005. 3 YA12 12, 16 The Manager must review service users assessed interests and must ensure that systems are in place to ensure they are supported to pursue individual identified
DS0000004840.V302330.R01.S.doc Timescale for action 31/10/06 2. YA9 13(4) 23/08/06 30/09/06 23 Barncroft Street Version 5.2 Page 28 interests e.g. drama, typing, computing etc New Requirement at this inspection, August 2006. Arrangements for contact with family must be reviewed for each service user, any agreements recorded in the care plan and contact clearly evidenced to facilitate easy monitoring of the plan’s effectiveness. New Requirements at August 2005 5. YA17 S 3 (3)(m) 13(4) 16(2)(i) Risks (identified from nutritional assessments carried out) must be included in a plan of care, which must be carried out, reviewed and evidenced. All service users must be regularly weighed and the results must inform the risk assessment and plan of care. Requirements made August 2005 The Manager must review the provision of deserts to ensure the availability of greater variation in accordance with assessed preference and need. New Requirement at August 2006. 6. YA19 12, 13 To ensure that specialist services (e.g. dietician) are consulted with a view to risk assessing and implementing any dietary constraints or weight reducing measures.
DS0000004840.V302330.R01.S.doc 4. YA15 12, 15 30/09/06 30/09/06 30/09/06 23 Barncroft Street Version 5.2 Page 29 Tissue viability awareness training is provided for the Acting Manager, senior staff and the care staff. New requirement at December 2005. 7 YA20 13(2) The Manager must take steps to ensure an improvement in handwritten Medication Administration Records as advised by the supplying support pharmacist. The manager must ensure that all prescribed medications, ointments, drops and topical creams are administered as per directed and that written directions are clear and accurate. The Manager must confirm in writing to CSCI what improvements will be made and how she will ensure that this is maintained. All errors in the administration of prescribed medication / creams etc must be reported in writing to CSCI without delay. New Requirement at this inspection, August 2006. 30/09/06 The service user who has funded lunches out must be fully reimbursed. The amount and period reimbursed must be confirmed in writing to CSCI. The Manager must ensure that she complies without
23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 30 15/09/06 8 YA23 13(6) delay with the organisations protocols in relation to the need to obtain authorisation for expenditure over £100.00 on behalf of service users. New Requirement at this inspection, August 2006. The manager must ensure that a maintenance programme is developed to include a plan with targets dates to address the following: The provision of ramps to exit the premises in the event of fire as per fire risk assessment. New Requirement at August 2005 At December 2005 target dates not provided. Work must therefore be completed by end of April 2006 – not met. 10. YA35 18 New staff must receive appropriate induction training (LDAFF) within 6 weeks of appointment. 30/09/06 9. YA24 23 31/10/06 11 YA39 24 New Requirement at December 2005. 30/11/06 The Registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the home based upon consultation with service users and their representatives. New requirement at this inspection, August 2006. 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 31 12 YA42 13(4) All hazardous chemicals must be stored appropriately in accordance with control measures indicated in the respective COSHH assessment 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 32 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 23 Barncroft Street DS0000004840.V302330.R01.S.doc Version 5.2 Page 33 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
