Inspection on 15/06/06 for 34 Pedmore Walk

This inspection was carried out on 15th June 2006.

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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Pedmore Walk 20/06/07

34 Pedmore Walk 22/11/05

34 Pedmore Walk 07/07/05

34 Pedmore Walk 15/02/05

34 Pedmore Walk 20/07/04

34 Pedmore Walk 20/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 34 Pedmore Walk Oldbury West Midlands B69 1BJ Lead Inspector Jayne Fisher Unannounced Inspection 15th June 2006 09:30 34 Pedmore Walk DS0000004794.V299651.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 34 Pedmore Walk DS0000004794.V299651.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. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Pedmore Walk Address Oldbury West Midlands B69 1BJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 552 3645 0121 552 3645 pedmore@sandwellcct.org.uk Sandwell Community Caring Trust Philippa Katherine Whitehouse Care Home 8 Category(ies) of Learning disability (8), Physical disability (8), registration, with number Sensory impairment (8) of places 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 8 PD, 8 SI and up to 8 LD Date of last inspection 22 November 2005 Brief Description of the Service: Pedmore Walk is a care home provision for 8 adults with severe learning disabilities who also have physical and sensory disabilities. The Home was originally a purpose built two storey childrens home situated in a residential area in Oldbury. The Home is approached via a pedestrian walkway adjacent to a school playing field. There is space for two vehicles in the secluded garden area at the rear of the property. A small block of shops is within easy walking distance and there is a good public transport system. The design and location of the Home blends in well with the local community. The Home has eight single bedrooms none of which are ensuite, located on the first floor and which are accessed by residents via a shaft lift. The majority of service users attend differing forms of day care, which are either local authority or communitybased resources. The Home has the use of its own mini bus to enable residents to access the community. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels were provided on 6 June 2006 which are £1,037.90 per week. There are additional charges for chiropody, toiletries and hairdressing. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 09:30 a.m. and 18:30 p.m. hours. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the operations manager and seven staff. Feedback was also received via comment cards from four relatives. All service users were at home during varying stages of the inspection, but formal interviews were not appropriate. Therefore the inspector relied upon brief chats, observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users. Three residents’ care was case tracked by reading and assessing care documents, observing interactions and by talking to staff. One mealtime was observed and drug administration. A tour of the premises was undertaken to assess the standard of the environment. Staff personnel files were accessed and a sample of maintenance and service records were examined. Other documentation was reviewed including a pre-inspection questionnaire completed by the manager and action plan sent by the provider, plus copies of visits undertaken by senior managers and other relevant information. The manager and deputy were not present at the inspection but staff were helpful and knowledgeable and co-operated fully with support from the operations manager. What the service does well: Daily routines are flexible and residents’ privacy and dignity is respected by staff. The atmosphere was relaxed and friendly, staff were overhead laughing and joking with residents who looked comfortably and happy in their surroundings. Residents were dressed in clean and modern clothing with accessories and grooming which reflected their individual personalities. Bedrooms are also decorated and furnished in different colour schemes and contained lots of residents’ own personal possessions. Staff support residents to maintain contact with families thereby promoting important relationships. Meals and mealtimes are relaxed and unhurried. Staff are proactive in quickly identifying any potential health care complications and seeking advice and treatment. There is a clear complaints procedure for service users and relatives, thereby ensuring individuals views and concerns would be listened to and acted upon. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 6 There is a stable and competent staff team who are dedicated and demonstrate a caring approach to residents. Staff are well qualified and trained in a number of areas in order to provide specialist support to residents. The team are supported by a skilled and experienced manager who is approachable and proactive in raising standards. What has improved since the last inspection? What they could do better: 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. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 7 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 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 8 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 The overall outcome for this group of standards is judged to be good. Quality in this outcome group is good. There is a good assessment tool for using in the event of a vacancy and admission of a new service user. EVIDENCE: Previously the service has been able to demonstrate that a thorough assessment has taken place with regard to a new resident who was admitted last year. There are a range of ‘personal data’ sheets which can be used to assess new residents which cover all of the topics required by the National Minimum Standards 2. The home currently has no vacancies. There is an outstanding requirement with regard to updating the statement of purpose in relation to environmental standards as per required by the National Minimum Standards 1. On the day of the inspection visit staff were unable to locate the statement of purpose. A copy had not been forwarded to the Commission for Social Care Inspection as previously requested. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 9 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 and 9 The overall outcome for this group of standards is judged to be adequate. The system for care planning needs improvement as it does not provide all staff with easy access to information necessary in providing the care required by service users. Risk assessments are in place but not for all of the risks which are posed in delivery of care; an improved system would offer more protection to service users. EVIDENCE: A sample of care plans were examined and interviews were held with key workers and senior support staff. Whilst the care planning system has remained unchanged since the last visit, the manager is making progress in identifying a new format which hopefully will provide staff with more guidance and support. As stated at previous inspections, although case files contain a large amount of useful information, this represents an assessment of need and does not constitute a care plan. It is not possible to easily determine an individual’s current care regime. There are no aims or objectives, long term or short term goals identified. For example, one resident has autism spectrum disorder 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 10 (ASD) but there is no specific care plan in relation to his specialist needs as a result of ASD and how this affects his daily life. Care plans with regard to challenging behaviour are poor with no comprehensive management guidelines for staff in de-escalation or distraction techniques including descriptions of how different behaviours are exhibited by the individual resident. An entry in one resident’s care plan stated that ‘A’ is tending to become very ‘stubborn’ when asked to go to their room following an outburst of aggression. As discussed with staff all techniques for managing residents’ behaviour must be formally agreed as part of a multi-disciplinary team. It was reassuring to see that this resident and another service user with increased challenging behaviour, had been referred to psychologists for assessment and establishing of appropriate management behavioural guidelines. It was stated that staff were completing Antecedent behavioural consequence (ABC) charts; these need to be completed more consistently. For example, during May 2006, one residents’ care plan referred to two incidents of aggression but only one ABC report had been completed. Key workers review care plans on a monthly basis. One entry in March 2006 stated that the resident had had no behavioural issues yet this did not correlate with an ABC report which had been completed for an incident during March 2006. Although there are regular reviews of care plans by key workers and reviews held at day centres, the home needs to ensure that at least on a six monthly basis, significant others such as families and social workers are invited to review meetings. The operations manager stated that this is not routinely carried out but that if there were any issues they would access the community learning disability team. Excellent efforts to introduce a person centred planning approach have been made by staff. As a result essential life style plans are in place for some service users. These have yet to be completed with all residents. The quality of risk assessments is varied. For example, there was a good risk assessment in place with regard to one resident’s mobility and use of the hoist (including the hoist and winch on the home’s transport). The risk assessment in place for use of the resident’s wheelchair still requires expansion to include all potential risks associated with posture belts and other seating accessories as identified in medical device alert notices. There was a good risk assessment in place with regard to self-harm, however the risk assessment in place with regard to pressure area care still needs more detail. For example, it was stated ‘re-position when required’, but there was no further clarification (nor in the care plan). Staff were unsure as to why regular changes of position were not taking place (particularly during the night time) or whether this was based on clinical guidance. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 11 Whilst there were good risk assessments in place regarding bedrails these had not been reviewed since March 2005. There was a good risk assessment in place for one resident’s challenging behaviour however this had not been reviewed since January 2005. The risk assessment was scored as ‘low’. This requires updating particularly as this resident has had increased episodes of challenging behaviour which include physical aggression. Some case files contained different formats for risk assessments, not all were dated and signed, and in some cases had not been reviewed since November 2003. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 The overall outcome for this group of standards is judged to be poor. There are limited opportunities for service users to participate in stimulating activities and social inclusion in order to support and enrich their lives. Staff support residents to maintain important links with their families and ensure that residents’ rights are respected with regard to their privacy and dignity. Residents are offered a healthy and nutritious diet although more careful monitoring is needed for those residents who require specialist diets. EVIDENCE: Concerns were raised at the last inspection visit with regard to the lack of sufficient staffing levels to support residents to undertake stimulating activities in the home and community. Examination of records and interviews with staff confirm that there has been little improvement and in some instances there has been a deterioration particularly with regard to social inclusion. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 13 As previously, there are seven residents who attend day centres during the week. There are no individual activity planners for residents. In the past the home had used a four weekly planner to co-ordinate and plan activities for the forthcoming weeks, with residents being rotated in pairs to undertake outings and activities. Staff explained that this had been replaced by a weekly plan which is completed retrospectively. On examination this weekly activity record (which is not always dated or fully completed), demonstrated limited opportunities for residents to participate in stimulating and meaningful activities. For example, during a one week period, one resident had been supported to go shopping, two days were not completed and on four days staff had recorded: ‘not done, only three staff’, or ‘short staffed – not done’. Daily reports were also examined which failed to identify what (if any) activities were undertaken. Staff explained that the situation was compounded by the lack of drivers for the mini-bus. Which in turn meant on alternate weekends there were no drivers on duty this resulted in residents having to stay at home. During interviews staff expressed frustration and disappointment about the lack staff to support residents in this important aspect of their lives. (See further comment in standard 33). All relatives who completed feedback comment cards stated that they were made welcome by staff when visiting the home and could see their family member in private if they so wished. They stated that they were consulted about their relatives care and kept abreast of important matters. Further positive comments were made regarding the staff and the support they provided. During interviews staff gave good examples regard how they maintain residents’ dignity and observe body language and eye movements to determine whether residents are comfortable and happy with the support given. All bathrooms are fitted with privacy locks. Since the last inspection visit a different member of staff has taken responsibility for cooking. It was stated that the menu plan had changed as there were some meals which she was unable to cook, but it was reported that residents were enjoying their new menu. There are two alternatives for the main meal during the evening. On examination residents’ food intake charts did not always correlate with the meals depicted on the menu plan. Staff stated that the lack of drivers for the mini-bus had meant that on occasion the menus could not be followed because of the lack of appropriate food supplies and therefore another meal was substituted. Despite the fact that there are two alternatives for the evening meal, residents’ food intake records demonstrated that they were mainly having the same option. When asked how residents are supported to make their choices from this menu the cook stated that she would cook four portions of each option and then would rotate this the following week. Whilst it is acknowledged that staff are fully aware of residents’ likes and dislikes this is not always recorded in care plans. For example a key worker stated that one resident particularly 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 14 liked salad but could not find this in their care plan. It is pleasing to see that the menu now includes different breakfast options at weekends (as previously requested), examination of a sample of food intake records demonstrated that residents are still having cereals. It is recommended that consideration is given to devising more formal strategies to encourage choice making with guidelines for staff to follow. One resident is on a specialist diet due to high cholesterol and obesity as determined by their body mass index calculation, identified in their care plan. On examination food intake records demonstrated that the resident is following a high fat diet for example meals provided included cheese and potato pie, lasagne, sausages and corned beef. Weight records demonstrate that on the whole the resident is losing weight over the last twelve months, but recently their weight has started to fluctuate and during the last week they have gained 5 lb. During interviews two key workers could not locate the nutritional screening tools and assessments for two residents within their case files. These must be re-established. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The overall outcome for this group of standards is judged to be adequate. The health needs of residents are well met with evidence of good multidisciplinary working on a regular basis. The arrangements for control and administration of medication needs improvement as at present systems have the potential to place residents at risk. EVIDENCE: Interviews and observations confirmed that staff provide sensitive and flexible personal support to residents. For example, on the day of the visit one resident had suffered and seizure and it was therefore decided that it would be in her best interests and safety to remain at home. Residents’ dignity and safety was maintained as observed when staff were assisting with eating. Since the last inspection good efforts have been made by management and staff to address outstanding items in relation to health care for example by discussing issues of capacity to consent to invasive screening with the medical practitioner, the outcomes of which are fully recorded in care plans. Examination of health care records confirm that staff continue to be vigilant when monitoring health needs and react quickly to any potential problem. For 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 16 example, one resident has within the last couple of weeks been diagnosed as borderline diabetic and an information folder established for staff. Although there have been improvements with regard to the management of medication since the last visit further improvement is necessary. It was noted from examination of one member of staff’s supervision records that a drug error had recently occurred (this was not reported to the Commission for Social Care Inspection and was discussed with the operations manager). It was stated that advice had been sought from the pharmacist as is good practice. Examination of the medication administration record (MAR) sheet and associated health care records contained no information regarding this incident. There are weekly management checks which have identified problems in recording on MAR sheets and these are discussed with staff as seen in minutes from meetings. This is a good initiative. Examination of MAR sheets revealed a number of discrepancies. For example, one resident was recently prescribed a short course of Amoxicillin to be taken four times a day. On one occasion it had only been given three times a day and as a result the course took a fraction longer. There were two occasions when staff had entered the letter code ‘O’ which signifies ‘other’ but there was no explanation as to why this had been entered. There were some gaps in recording where there was no staff initial to confirm administration, on checking the monitored dosage system the medication had been administered. Other gaps could not be confirmed as they related to inhalers and eye drops. Staff are entering letter codes inappropriately. For example, on occasions when medication is not required, they are entering ‘O’ for ‘other’ instead of using the correct letter code. Where medication is not dispensed from the monitored dosage system staff are using the MAR sheet to keep a running balance of the medication. Whilst this is not the purpose of the MAR sheet it has also resulted in staff not signing initials to confirm administration as they have no space left on which to record this on the MAR sheet, once they have entered the running balance of the medication. Progress has been slow towards trying to secure accredited training in the safe handling of medication. In the interim training has been given to staff by local pharmacists. It was noted that there are some staff who are administering medication who have received no training. A risk assessment was in place and included information that staff had been ‘trained’ internally by senior staff. This must be formalised and competency monitoring must also be implemented. There was a number of ‘as and when required’ PRN medication. but staff could not locate guidelines with regard to administration which needs to be addressed. Any other items discussed during this inspection are contained within the Requirements section of this report. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The overall outcome for this group of standards is judged to be good. There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. There are procedures in place to safeguard service users from abuse. EVIDENCE: There have been no complaints regarding the service since the last visit. There has been a verbal complaint by a neighbour on examination of the complaints log which the manager has proactively dealt with. There is a comprehensive complaints systems and feedback from all relatives confirmed that they were aware of this process. There are good systems in place to protection service users from adult abuse. Recruitment and selection procedures are improved and staff have received training. During interviews staff gave very good responses to how they would deal with potential vulnerable adult abuse incidents. There were copies of important documents on the premises such as the Local Authority Multi-Agency Vulnerable Adult abuse procedures. The organisation’s own policy still requires amendment and updating in line with legislation. Improvements have been made with regard to managing service users’ finances. A sample of records balanced accurately with monies held on the premises, monies are regularly audited and there are two staff signatures for all financial transactions undertaken on behalf of residents. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 18 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, 25, 26, 27, 28, 29 and 30 The overall outcome for this group of standards is judged to be poor. The standard of décor and furnishing is poor with slow progress made towards refurbishment. The home does not, therefore, promote as a homely and attractive place for service users to live. The building and environmental adaptations do not meet the needs of persons with physical disabilities and thereby limits residents’ independence and compromises dignity. EVIDENCE: There were a number of requirements made with regard to refurbishment at the last inspection in November 2005 due to the continuing deteriorating environment. Only a few items have been addressed. Staff reported that the refurbishment programme had started a few days earlier but expressed frustration that the contractors had left because they had a more ‘important’ job to do elsewhere. It was evident that work had started with wallpaper borders torn off walls and some repairs to plasterwork in communal areas. It was disappointing that the decorators had seen fit to leave the home in such state. A tour of the premises revealed bedrooms and communal areas in need of redecoration and worn and (in some cases), broken furniture. Carpet is 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 19 stained and worn in some bedrooms and communal areas. In one bedroom carpeting has become loose and uneven which if not addressed in the near future could pose a health and safety risk. It was pleasing to see that Immediate Requirements issued at the last inspection visit have been addressed with regard to repairing loose paving slabs in the garden area. Although in some other areas of the patio paving slabs are slightly uneven. In the past concerns have been raised with regard to the building not being entirely suitable for persons with a physical disability. For example there is no overhead tracking. A request was made for this to be considered but unfortunately the structure of the building does not allow for this equipment to be safely fitted. Bedrooms are not all able to easily accommodate portable hoists; as a compromise risk assessments were accepted. There is no storage space for wheelchairs and hoists. The passenger lift will only accommodate one wheelchair user; a member of staff has to squeeze themselves in to a very tight space in order to escort wheelchair users between the floors. Corridors are narrow making turning manoeuvres difficult. As a result plasterwork and bedroom doors have become damaged. Although a new specialist bath was purchased in 2004 staff report difficulties in trying to use the hoist as the base of the equipment does not fit comfortably underneath the bath. As a result 3 members of staff are required to assist a resident to bathe. The garden is small and unattractive. Some new garden furniture has been purchased although there is still a worn table and bench seat set. The service provider is sourcing another premises as discussed at a meeting with the Commission for Social Care Inspection in December 2005. Overall infection control practice is acceptable. There are a couple of outstanding issues relating to the laundry room and ensuring grouting in bathrooms is kept clean. There were a couple of new items identified at this inspection, for example, the ironing board should not be stored in the laundry room and paper towels dispensers should be fitted to the kitchen area and shower room. Any other items discussed during this inspection are contained within the Requirements section of this report. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The overall outcome for this group of standards is judged to be adequate. There is a competent and well qualified staff group offering consistency of care for service users. Staffing levels need review as at present there is insufficient staff to meet all of service users’ needs. Recruitment and selection procedures are improved and offer enough more safeguards and protection for residents. Induction programmes need expansion to give staff more underpinning knowledge regarding the specialist needs of service users. EVIDENCE: At present the home employs 17 support workers. Nine staff are qualified to NVQ II or above which meets the National Minimum Standards (in that 50 of the staff team should be qualified to NVQ II by 2005). Specialist training is on-going. For example staff have received training in ASD, epilepsy, dementia, equality and disability, and diabetes awareness. Training in tissue viability is still outstanding. There is a stable core staff group. Shortfalls in the duty rota are covered by relief staff employed by the organisation. As already stated in this report there are issues with regard to staffing levels which impact upon service users’ 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 21 ability to access the community and to participate in stimulating activities when not in attendance at their day centres. These require review as do service users’ dependency levels some of which were seen to be increased. Examination of the duty rota reveals that there are three support staff on duty for the majority of shifts. On occasions this is increased to four and five support staff. Two of the four relatives who responded felt that there are not always sufficient number of staff on duty. Examination of a recently employed relief staff worker’s personnel file confirms that there is an improved recruitment and selection process. All of the requirement pre-employment checks had been undertaken. Two further relief staff files were examined. As discussed with the operations manager, improvements are needed with regard to ensuring that recent photographs are held on files. There were some gaps in one person’s employment history and a criminal record bureau (CRB) disclosure had been provided by a former employer. These issues were previously discussed at a meeting with the service provider in December 2005 (the member of staff had been recruited prior to this date). It is also recommended that reference proformas are amended to include a date of completion in order to demonstrate when the referee provided the reference. As at present there is no confirmation of when references are received or completed. No progress has been made in providing new staff with an induction and foundation programme that is undertaken by an accredited learning disability awards framework (LDAF) trainer. Although there is a comprehensive induction programme which is run in-house, it is a requirement of the National Minimum Standards and the White Paper ‘Valuing People’ that from April 2002 all new entrants to learning disability should be registered for a qualification with LDAF. There was no central staff training matrix on the premises. The operations manager states that this is because training is now co-ordinated from the organisation’s head office. A copy must be held on the premises. A full training audit did not take place as a result. A sample of training certificates and individual staff training profiles were examined as a compromise. It was pleasing to see that there is regular and formal supervision of staff. Proactive action is taken with staff failing to attend planned supervision as is good practice. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 22 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 and 42 The overall outcome for this group of standards is judged to be adequate. Service users and staff are supported by a competent manager. Quality assurance systems require further improvement in order for all users to be confident that their views underpin the development of the home. Overall there is good health and safety practice although some elements need improvement in order to offer residents more safeguards. EVIDENCE: Although the manager was not present during the inspection visit, it was still possible to gather evidence to confirm that the home continues to be run by a competent and dedicated manager. There are regular staff meetings and supervision sessions. Good records are maintained and a range of subjects are discussed. There is good accident reporting which the manager reviews on a regular basis. During interviews staff confirmed that they can approach the manager or deputy if they have any problems. All relatives who completed 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 23 comment cards confirmed that they were satisfied with the overall care provided at Pedmore Walk. At present the manager does not hold a management qualification and the service provider is required to provide the CSCI with an individual personal development plan for the manager in order to demonstrate how they will be supporting Ms. Whitehouse to complete a relevant qualification within the timescales required by the new guidance issued by the CSCI. Staff personnel files are not held on the premises. New guidance has been issued by the CSCI with regard to this and will be discussed with the service provider. Since the last visit staff have received training in how to disable the passenger lift in case of emergency. As previously stated a full audit could not be undertaken of staff mandatory training as there was no central staff training matrix. Samples of training certificates and interviews with staff confirmed that they had received the required mandatory training. A sample of maintenance and service records were examined. These were largely found to be up to date with a couple of exceptions. For example, portable appliance testing has not been carried out during the last twelve months although it was pleasing to see that this had been identified at a recent health and safety risk assessment and is being actioned. Other areas for improvement included: lack of up to date servicing of hoisting and lifting equipment. For example the hoist had not been serviced since October 2005. (in compliance with the Lifting Operations and Lifting Equipment Regulations 1998 this should normally be carried out on a six monthly basis. According to fire drill records two fire safety evacuations had been carried out since September 2005, but not all staff had participated in a fire drills (all staff should participate in a bi-annual fire evacuation drill). There was an issue identified following examination of a moving and handling risk assessment and interviews with staff. Due to concerns staff have recently devised new moving and handling techniques for one resident to manage the stairs. As discussed practice adopted is unsafe and must cease immediately. A review by a moving and handling assessor or occupational therapist must be carried out and the risk assessment accordingly updated. There were good elements of food hygiene practice but improvement is required in some areas. For example: there were inconsistencies noted in daily checking and recording of fridge temperatures and cooked food temperatures. In particular a barbeque had been held the previous week and no cooked food temperatures had been recorded. It was pleasing to see that all dried foods were stored appropriately and frozen produce was labelled with the date of freezing. All high-risk foods were seen to be stored appropriately. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 24 Any other items discussed during this inspection visit are contained within the Requirements section of this report. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X 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 1 25 1 26 1 27 1 28 1 29 1 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 1 14 1 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6 Requirement The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2. The statement of purpose must also include individual measurements of bedroom and communal space. A copy must be forwarded to the Commission for Social Care Inspection (CSCI) upon completion. (Previous timescale of 1/7/05 is partly met). To review and expand service user plans to include goals and objectives relating to all aspects of care including: personal care, social inclusion, community activities, leisure, social care, health care and family contact. (Previous timescale of 1/1/05 is not met). To introduce a person centred planning process using a 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 27 Timescale for action 01/10/06 2. YA6 15(1) 01/10/06 recognised format such as essential life style planning and life story books. (Previous timescale of 1/1/05 is partly met). To demonstrate that six monthly reviews are undertaken with the involvement of the service user and involving significant professionals, family, friends and advocates). To ensure there are written risk assessments established for all aspects of service users lives which pose a risk, for example: wheelchair use, self harm, use of the passenger lift etc. (Previous timescale of 1/9/05 is partly met). 3. YA9 13(4)(c) 01/09/06 4. YA12 16(2)(n) To ensure that activity records 01/08/06 are more consistently completed by staff on a daily basis. (Previous timescale of 1/2/06 is not met). To provide more opportunities 01/09/06 for service users to partipate in the local community through outings and structured activities. To provide more opportunities 01/09/06 for service users to engage in stimulating and appropriate leisure activities based upon their individual preferences and needs. To undertake a review of the 01/10/06 menu to expand the choice for breakfast (for example at weekends). (Previous timescale of 1/2/06 is partly met). To ensure that where a Page 28 5. YA13 16(2)(m) 6. YA14 16(2)(n) 7. YA17 16(2)(i) 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 service user is identified as having increased dietary needs due to health complications, that specialist menu plans are more closely adhered to, and that staff are more familiar with their dietary requirements. To re-establish nutritional screening tools to ensure that service users’ nutritional needs are regularly assessed and reviewed including risk factors associated with low weight, obesity and health complications. 8. YA20 13(2) 1) To review and update the 01/10/06 medication policy to follow good practice identified in the Royal Pharmaceutical Society guidelines for the control and administration of medication issued in June 2003. To forward a copy to the Commission for Social Care Inspection (CSCI). (Previous timescale of 1/6/05 is not met). 2) To continue to progress training for staff in the safe handling of medication from an accredited training provider. (Previous timescale of 1/10/05 is partly met). 3) To ensure that all tubs, tubes and bottles are labelled with the date of opening and to dispose of any medicines which the expiry date has exceeded. 4) A staff competency monitoring procedure to 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 29 ensure the correct administration of medication must be developed and completed on a regular basis with records maintained. 5) The home must improve medication administration, and record keeping with regard to the Medication Administration Record (MAR) charts. To ensure that all MAR charts are accurate and up to date with appropriate letter codes entered to confirm whether or not medicines have been administered. 6) To ensure that detailed guidelines are established for all ‘as and when required’ (PRN) medications – for example: when precisely the medication can be administered, what the initial dose to be administered is, what the maximum daily dosage is, how long the treatment should be continued for before further advice is sought from medical practitioners. Copies must be held on individual service users’ case files or central medication folder. To expand the vulnerable 01/10/06 adult abuse policy to include procedures on the Protection of Vulnerable Adult (POVA) scheme in respect of staff being referred to the scheme on a temporary basis whilst undergoing investigation. (Previous timescale of 1/11/05 is not met). To undertake the following DS0000004794.V299651.R01.S.doc 9. YA23 13(6) 10. YA24 23(2)(p) 01/10/06 Page 30 34 Pedmore Walk Version 5.2 improvements to the premises: 1) To explore the lack of water and low water pressure in first floor bathroom and carry out required repairs. (Previous timescale of 1/9/04 is not met). 2) To replace all stained carpeting in communal areas and bedroom areas. (Previous timescale of 1/11/05 is not met). 3) To replace all worn and broken furniture in communal areas (dining room) and individual bedrooms. (Previous timescale of 1/11/05 is not met). 4) To regrout stained tiling in shower room and clean stained tiling in bathroom. (Previous timescale of 1/11/05 is partly met). 5) To replace worn garden furniture. (Previous timescale of 1/11/05 is partly met). 6) To remove unsuitable signage in service users bedrooms. (Previous timescale of 1/11/05 is not met). 7) To repair all doors which have been damaged by wheelchair use. (Previous timescale of 1/11/05 is not met). 8) To remove staff lockers from the laundry area. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 31 (Previous timescale of 1/11/05 is not met). 9) To provide the Commission for Social Care Inspection (CSCI) with an updated written programme of refurbishment together with timescales for completion by 31 July 2006. 10) To ensure that all wardrobes are securely fixed to bedroom walls. 11) To replace worn suite in lounge area. 11. YA33 18(1)(a) The Manager must undertake an up to date review of staffing ratios and service users dependency levels. To forward proposals to the Commission for Social Care Inspection. Sufficient staff must be allocated on a daily basis to provide all service users with a range of stimulating activities and to meet personal development needs. 01/08/06 12. YA35 18(1)(c) To ensure that the duty rota is more accurately completed for example with regard to the full names of staff and clearer recording of off duty staff. 01/10/06 1) To provide induction and foundation training which meets all of the specifications of the Sector Skills Council which must be carried out within the first six weeks and first six months of employment. To ensure that this is provided by an accredited Learning Disability Awards Framework trainer. DS0000004794.V299651.R01.S.doc Version 5.2 Page 32 34 Pedmore Walk (Previous timescale of 1/1/05 is not met) 2) To ensure that a written staff training and development programme is held on the premises and made available for inspection. 13. YA37 18(1)(c) To ensure that the manager is qualified to NVQ IV in management by 2005. (Previous timescale of 1/1/06 is not met). To establish and forward an individual personal development plan for the manager of Pedmore Walk to CSCI by 1 September 2006. 01/10/06 14. YA39 24 To review and further develop the quality assurance system - to seek feedback from stakeholders, other professionals, families and advocates. (Previous timescale of 1/7/05 is partly met). 01/10/06 15. YA41 13(6)19(1)(b) To obtain and hold 01/10/06 information and documents on the care homes premises in respect of persons carrying on, managing or working at a care home as listed in 4 of the Care homes Regulations 2001. (Previous timescale of 1/10/05 is not met). 13(4)(c) To review and expand the Legionella risk assessment. (Previous timescale of 1/11/05 is not met). 01/09/06 16. YA42 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 33 To establish regular and recorded maintenance checks on all wheelchairs, hoists and bedrails (to supplement periodic servicing). (Previous timescale of 1/2/06 is not met). The Registered Manager is required to ensure the health, safety and welfare of service users and staff in relation to safe working practices, and associated routines in the home, in addition to deficiencies noted about the premises as detailed in the report (for example food hygiene practice). To ensure that all lifting equipment is serviced and inspected on a regular basis as in compliance with the Lifting Operations and Lifting Equipment Regulations 1998 with records/certificates maintained and held on the premises. To cease inappropriate moving and handling of identified service user when supporting to access the stairs and review with appropriate professional, updating written guidelines in risk assessment. To review and expand the fire 01/09/06 safety risk assessment. This must cover all aspects of fire safety and be specific to Pedmore Walk. (Previous timescale of 1/5/05 is not met). To cease the use of a door wedge and to repair broken Dorguard fixed to the office 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 34 17. YA42 23(4)(a)(v) door. To ensure that all staff participate in a bi-annual fire safety evacuation drill with records maintained of staff who have participated. 18. YA43 25 To ensure that there is a written report on the conduct of the home completed by the providers representative who is carrying out monthly visits. A copy must be provided to the Registered Manager and a copy forwarded to the Commission for Social Care Inspection. (Previous timescale of 1/10/05 is not met). 01/09/06 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 YA14 Good Practice Recommendations To consider re-introducing structured weekly activity planners or activity planners for individual service users. To seek advice from manufacturers with regard to freezing of fresh pre-packed processed meats and other products such as margarine. To provide staff with guidance regarding exploring different strategies for enabling residents to make choices from the daily menu and in menu planning. To ensure there is more consistency in completing food intake records. 2. YA17 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 35 3. YA30 To consider fitting a wash hand basin in the laundry room. To cease storing the ironing board in the laundry area. To consider fitting paper towel dispensers to the kitchen area and shower room. 4. 5. YA32 YA34 To consider providing staff with training in tissue viability awareness To ensure that reference proformas include the dates of when references are provided and received. To ensure that any dates of employment on references which do not correlate dates of employment given by the applicant are explored and outcomes recorded. 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 36 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 34 Pedmore Walk DS0000004794.V299651.R01.S.doc Version 5.2 Page 37 - 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!