Inspection on 20/06/07 for 34 Pedmore Walk

This inspection was carried out on 20th June 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Pedmore Walk 15/06/06

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 20th June 2007 09:15 34 Pedmore Walk DS0000004794.V336616.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.V336616.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.V336616.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 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.V336616.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 15th June 2006 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 walk way 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. All service users attend differing forms of day care, which are either local authority or community-based resources. The Home provides a wide range of recreational and leisure activities and has the use of its own mini bus. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels were provided on 25 June 2007 which are £1,037.90 per week. There are additional charges for chiropody, toiletries and hairdressing. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 09.15 a.m. and 7.00 p.m. and was undertaken by one inspector with the home being given no prior notice. On our arrival three residents were waiting to go to their day centres, a couple were remaining at home for the day and three were on holiday. Formal interviews were not appropriate so we relied upon brief chats and observations of body language and interactions with staff. We spoke with the registered manager, assistant manager and three members of staff. Questionnaires were received from eleven relatives and visiting professionals. We looked around the home, examined records and observed care practice. We also looked at all of the information that we have received about this home since it was last inspected. What the service does well: The atmosphere through out our visit was relaxed and friendly. Residents looked comfortable and happy in their surroundings; there was lots of smiles and laughter with staff. Upon return from their day centres and holiday residents were greeted warmly by staff and looked happy to be back at their home. All residents’ needs are thoroughly assessed so that staff can ensure that any new needs are identified and met. Staff enable residents to participate in decision making and expressing their wishes through a person centred planning system which they have drawn up with other people who play an important part their lives. Relatives are warmly welcomed by staff and encouraged to take an active role in maintaining important links with their family member. Health care needs are fully met and swift action is taken when any resident becomes unwell. Management and staff champion residents’ rights and ensure that they have access to the required health care. Staff understand the need to promote residents’ dignity and privacy. Meal times are relaxed and residents are assisted by staff in a discreet and patient manner. There is a complaints procedure in place so that people can be assured their views are listened to. There are systems in place to protect and safeguard residents from abuse. Bedrooms are decorated and furnished according to residents’ individual tastes and personalities. Staff have taken the time to purchase colour co-ordinated furnishings and ornaments and make the rooms comfortable and homely. All bedrooms and other parts of the home were clean and smelt fresh. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 6 The staff team who are employed reflect the cultural needs of the resident group. They are qualified and have received specific training in order to meet the specialised and complex needs of residents. Recruitment and selection procedures offer suitable safeguards to residents. Staff are supported by a competent and experienced manager who clearly runs the home in the best interests of the residents. What has improved since the last inspection? What they could do better: Although there has been an increase in staffing levels, there is still insufficient staff to meet residents’ individual preferences and needs particularly with regard to activities and outings. As a result, residents have to take turns in participating in community based activities and have to go out in groups or pairs. Activities and outings could also be more varied but are limited by staffing constraints. This has been recognised by the Local Authority who are going to reassess residents’ needs and look at funding arrangements. There is a vacancy for a dedicated cook. It was noted that the menu could be made more seasonal with more focus on home made meals. The environment is not wholly suitable for people who have physical disabilities due to the lack of space and equipment which would promote their independence and dignity. This is recognised by the provider who has been looking to move to a more suitable premises since 2005. No progress has been made. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 7 The are currently three male residents but there is only one male member of staff employed which provides limited choice for residents regarding which gender they would like to support them. A comprehensive quality assurance system still needs to be introduced so that people can be assured their views will be included regarding the development of the service. 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. The summary of this inspection report can be made available in other formats on request. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and existing service users have a range of information they need to make choices about where to live. There is a good assessment tool for using in the event of a vacancy and admission of a new resident. EVIDENCE: We saw that there is an informative service user guide which has been produced in a photographic format to aid residents’ understanding of the services to which they are entitled. There is also a detailed statement of purpose and the manager has included specific room measurements. We have asked the manager to include more details about how the physical layout of the home does not meet all of the needs of the resident group who may have a physical disability. It is also recommended that the document clearly sets out the environmental standards met by the home in relation to standards of 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2 as required by the National Minimum Standards (NMS) 1.1. The home remains fully occupied. There have been no new admissions to the home since February 2005. The last person to be admitted is still happily 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 10 living at the home which demonstrates the effectiveness of the admission procedure. We met the resident and spoke briefly with him before he went to his day centre. His health and appearance has clearly improved since he moved into the home and he was smiling and chatty. There are a range of ‘personal data’ sheets which form a comprehensive assessment tool and these cover all of the topics required by the NMS. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements made to the care planning systems have resulted in a clearer, and more person centred approach for staff to follow when supporting residents. Residents are enabled to make decisions through person centred planning. There are a range of risk assessments in place but not all potential hazards to which residents are exposed have been assessed. EVIDENCE: Whilst there has always been a range of comprehensive information held about residents’ individual needs, in the past this has not been translated into care plans. We saw that great improvements have been made at rectifying this deficiency. New style care plans have been introduced which are clear and easy for staff to follow and have a person centred approach. Care plans are divided into section headings entitled ‘goal, requirement, why, how, when and the desired outcome’. We saw that all areas of residents’ personal and social support and health care needs are included with only one exception seen in 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 12 one person’s care plan. This resident has recently displayed an episode of challenging behaviour which was atypical but did involve some level of aggression towards others. A care plan has been started but is not completed and there are no behavioural management guidelines. When we interviewed staff there was a slight variation in their description of how they would manage the behaviour and they were not fully familiar with the recommendations that had been made by psychologists as detailed in their report dated December 2006. As we discussed with the manager, the recommendations made need to be included in the care plan. We were reassured that the manager was able to demonstrate that she had arranged a meeting with the operational manager to discuss and establish the care plan on behalf of the resident. Relatives confirmed that they are involved in meetings to review their residents’ care and support. All relatives and professionals who completed comment cards said that they felt residents wee supported by staff to make decisions. 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 all but one resident. The manager told us that she had delayed this because the resident had undergone an intensive period of ill health and as a result many meetings had been arranged. There are care plans in place regarding how residents are enabled with their decision making and their communication needs. We observed staff communicating effectively with residents through out our visit. There are a range of detailed risk assessments in place covering a wide selection of topics. One risk assessment had been updated with advice from an Occupational Therapist regarding moving and handling. Interviews with staff confirmed that their were aware of this advice and followed the guidelines in the risk assessment. There was only one area which we have asked to be expanded upon. One resident occasionally requires the use of a wheelchair which had not been risk assessed. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally residents are enabled to lead meaningful lifestyles although on occasions these are restricted by insufficient staff being available. Staff support residents to maintain important links with their families. Mealtimes are relaxed and unhurried and residents are offered a balanced and varied diet. However, the menu needs to be reviewed to include more freshly cooked and seasonal dishes. A pictorial menu may of benefit to some residents. EVIDENCE: All residents attend some form of external day care or college provision. Whilst there has been some improvement with regard to staffing levels since our last visit, and there are more staff who are trained to drive the mini-bus, residents’ activities and outings can at times still be restricted due to insufficient staff. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 14 Two relatives commented about inadequate staffing levels, one person said: “I think the home would improve if there were more staff. A few months ago there were one or sometimes two relief staff brought into the home and things were a lot better, residents were able to go out more often and the ones left at home had more activities due to the help for the permanent staff. But sadly, this only lasted a few weeks then things went back to how they used to be”. We interviewed staff who felt that while staffing levels were improved, they were still not meeting all of the needs of residents with regard to their activities and outings. One staff member said “it is difficult when there are only four staff on duty, particularly to get the residents out. If there is no driver they walk around the estate or go to the pub”. We looked at activity records and saw that staff are completing these more consistently and that residents are going out more regularly than when we last visited. However, generally residents have to go out in groups rather than as individuals as there are not enough staff to accommodate their individual preferences. For example, during a twenty day period that we case tracked, all outings that were undertaken were either in pairs our groups. All residents require one to one support from staff when out in the community, therefore if there are only 4 staff on duty this inevitably means that only 2 people can go out, and the remaining 6 residents are supported at the home by 2 members of staff. The majority of outings are shopping trips. The manager told us that the lack of variety was due to staffing constraints and shift patterns. On one occasion a community based activity for two residents had been cancelled due to lack of transport. All relatives who completed comment cards confirmed that staff helped their family member to keep in touch with them. One relative told us: “every time we visit we are made very welcome, and everyone is so friendly, also very helpful and polite when I phone to see how every is getting on”. Daily routines respect residents’ privacy. There are locks fitted to bathrooms and toilets. Through out our visit we saw or overheard staff talking directly to residents rather than chatting between themselves. One relative stated: “they always respect her privacy”. We observed one meal time. This was relaxed and leisurely. Staff took the time to explain to residents what they were having for lunch and assisted them to eat their food discretely and with dignity. There was lots of eye contact and smiles. One resident had pasta (frozen ready meal), and the other a brown bread sandwich with a crispy snack. Residents looked like they enjoyed their meal. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 15 We looked at residents’ food intake records and saw that specialist dietary requirements are more closely adhered to. There is a very useful list displayed in the kitchen of residents’ specialist needs and equipment. The manager told us that she has obtained the advice and approval from a community dietician with regard to the menu plan. There is a four weekly rolling menu. There are two options for the main meal and residents have a variety of choice for breakfast. We looked at two residents’ food intake records. These demonstrated that the residents mainly had the same meal option despite there being two choices available. The manager explained that both residents were on a low fat diet and therefore had received the low fat option. It is accepted that staff do have to rely upon their knowledge of residents’ known likes and dislikes, (which are recorded), when offering choices, however it is suggested that ‘taster’ sessions are introduced so that from time to time residents can experience different foods to establish if their preferences have changed. For the evening meal we saw staff preparing jacket potatoes, frozen pizza and frozen lasagne. The manager told us that she is still trying to employ a dedicated cook who will take on the responsibility for menu planning and focus on home made meals. Staff are currently undertaking training in nutrition. We did note that some of the meals on the current menu plan could be made more seasonal. There is no pictorial menu and management agreed that some residents may possibly benefit from having such an aid. There were ample supplies of fresh fruit, salad and vegetables available. We saw that nutritional screening tools have been reviewed. 34 Pedmore Walk DS0000004794.V336616.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in such a way as to protect service users’ dignity and promote independence. The health needs of service users are well met. There are safer systems in place for residents to receive their medication only slight improvements are necessary to enhance current practice. EVIDENCE: We saw that care plans contained information regarding residents’ preferences with regard to how they receive support. These include detailed guidelines for staff regarding their preferred getting up and going to bed times, how they like assistance with washing, dressing and skin care. There are also details regarding ‘gender sensitive care’. The manager has undertaken training in the new Mental Capacity Act 2005 and is aware of how this impacts upon making decisions in the best interests of residents. We saw that residents’ clothing and grooming reflected their age, ethnicity and individual personalities. The home employs staff from different ethnic backgrounds which is representative of the diverse needs of the resident 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 17 group, although it would be beneficial to employ more male staff which is recognised by the manager. All relatives and professionals who completed comment cards stated that they felt residents’ different needs were met. Comments included: “the staff are all very caring and loving to all of the residents there. They are all polite and helpful to me during my visits”. “X receives an excellent person centred service”. “the care home does very well in keeping our sister’s appearance clean and smart and always makes us welcome”. Discussions with staff, examination of records and feedback from relatives and professionals confirms that the health needs of residents continue to be a priority and are fully met. The manager demonstrates a proactive attitude towards ensuring that residents receive the health care to which they are entitled and support needed to access treatment and in some cases overcome prejudice towards people who have a learning disability. We commend the management and staff for their approach and tenacity. We looked at healthcare records and saw that residents have access to a range of specialists and routine health checks. There are monthly weight checks and some residents are losing weight as part of an agreed weight loss regime. Comments from relatives and professionals include: “myself and family are always kept informed regarding X’s health no matter what the problem”. . “our daughter has had to put up with a lot health wise, but every time she has had a problem, Pedmore has been quick to act which I find very reassuring as I live many miles away. Excellent attention given always”. “Contact is regular and any changes are notified immediately”. We looked at the medication systems in place and found them to be satisfactory. Improvements have been made including: staff training, the introduction of competency monitoring tests, and creams and ointments were labelled with the date of opening. There were less gaps found in the medication administration record (MAR) sheets. Although a few gaps were seen with regard to ‘as and when required’ (PRN) creams, staff thought that this was because the application was not necessary. It was suggested that a letter code is used to signify when treatment has ceased. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 18 There were detailed PRN guidelines in place apart from a couple of medications where staff thought that they had been removed by other staff for review or taking on holiday with residents. We suggested only a couple of improvements were necessary. For example, residents had gone on holiday but there had been no record as to what and how much medication had been taken out of the home. It is also suggested that a record of this is maintained when residents go and stay with their families as well as a system for checking the medication back into the home. It is also recommended that a running balance is checked and carried forward of any PRN medication which is not dispensed on a monthly basis. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive complaints system which ensures that people’s views are listened to and acted upon. There are procedures in place to safeguard residents from abuse. EVIDENCE: There is a comprehensive complaints procedure which is also included in the statement of purpose. There have been no complaints made during the last twelve months. All relatives and professionals who completed comment cards stated that they were aware of how to make a complaint. People made the following statements: “Myself and family have never had to make a complaint we are very happy with the way X is being taken care of”. “I haven’t had any reason to raise any concerns, they all seem to be one big happy family”. “Any issues are dealt with immediately.” The manager told us that the adult protection procedure has been updated since we last visited. We saw that there was a copy of the Local Authority vulnerable adult abuse procedures held in the office for staff to reference. We 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 20 interviewed support staff who were aware of what to do in the event of a potential incident of abuse and they confirmed that they had received training. There has been one incident of potential adult abuse involving one resident who acted aggressively towards another resident. We asked that this be reported to the Local Authority who carried out a preliminary investigation and found that there was no intended abuse and systems were safe although a reassessment of the resident’s needs is to be carried out. As we have already stated one resident has exhibited challenging behaviour which resulted in aggression towards other people. This was reported appropriately to the Commission. Upon case tracking we found that good records had bee maintained with an accident report and corresponding antecedent behavioural consequence chart. Interviews with staff who were present confirmed that appropriate procedures were followed. We suggested that the length of time of the restraint is fully recorded as well as confirmation as to what debriefing took place for residents and staff. Case files contained residents’ personal expenditure sheets. There were double signatures from staff for all transactions and receipts are obtained with tallied with purchases made. All residents have Local Authority appointees to help them manage their finances. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made towards the standard of décor and furnishings so that residents live in a more pleasant environment, although the refurbishment programme is not yet fully completed. The building and environmental adaptations do not meet all the needs of persons with physical disabilities and thereby limits residents’ independence and can compromise dignity. The home is clean, free from odours and hygienic. EVIDENCE: We toured the building to look at what improvements had been made since our last visit. We saw that there is new carpet in communal areas and these have been redecorated and refurbished. The manager told us that a new hot water system has been installed and there is now adequate water pressure. The shower room has been regrouted and redecorated (although grouting has once again become stained). Some residents’ bedrooms have had new flooring and 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 22 staff told us that it was now easier to manoeuvre the portable hoists. Unfortunately although the carpets have been replaced, they are becoming stained again due to heavy usage and we suggested that a routine deep cleaning programme is added to the cleaning schedule. The refurbishment programme is not yet completed. Five residents’ bedrooms still require redecoration and worn furniture needs replacing. Doors and paintwork still need to be repaired as they have been damaged by wheelchairs. All bedrooms that we saw were individually decorated and furnished. Staff have made good efforts at making these homely and inviting with colour coordinated furnishings, ornaments and some sensory equipment. New garden furniture has been purchased although the slabs at the side of the building are slightly uneven. Overall the garden is austere, uninviting and overgrown. Paintwork around the conservatory is peeling and needs repainting. In the past concerns have been raised with the provider 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. Seven of the eight residents are wheelchair users but only two of the bedrooms currently meet the National Minimum Standards of 12 sq. m. (new buildings are required to have 15 sq. m.). None of the bedrooms have ensuite facilities. 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 have reported 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 shower room is small and unable to accommodate any drying table or suitable storage for residents’ belongings whilst they are being showered. The garden is small. Comments from one relative included “they could do with a bigger premises, bigger dining room area and bigger bedrooms”. We met with the provider in 2005 when we were informed that a new premises was going to be looked for. The manager reports that as yet an ideal building has not been identified. The laundry is on the ground floor and since we last visited staff lockers have been removed and a new washing machine has been installed to improve 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 23 infection control procedures. The manager said that there was still a lockable space for staff to keep their belongings and that they were happy with the current arrangements. Paper towels dispensers have been fitted and the ironing board is no longer stored in the laundry. The clinical waste bin was locked and there are clinical waste receptacles within the communal bathrooms. There are sealed laundry boxes for the transportation of dirty laundry through the building. It is still recommended that a wash hand basin is installed in the laundry area. Staff were seen to wear appropriate protective clothing whilst preparing meals in the kitchen. All parts of the home smelt fresh and were clean and tidy with suitable lighting. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a qualified and enthusiastic staff group. However staffing shortages are having an impact upon some areas of support provided to residents. Recruitment and selection practices offer protection to residents. Induction programmes need improvement in order to meet the specialized needs of residents. EVIDENCE: Interviews with staff and examination of the central training matrix and training certificates confirms that staff receive a range of specialist training including diabetes awareness, autism awareness, epilepsy, incontinence, and dementia. There is an outstanding recommendation to provide staff with training in tissue viability. One member of staff also stated that she thought some training in Parkinson’s Disease may also prove beneficial. The majority of staff have received training in managing challenging behaviour although some of this was carried out in 2002 and 2004 and is out of date being valid for only one year. In addition, we discussed the necessity of providing staff with some formal accredited training in physical intervention given that on one occasion in the past restraint has had to be employed. The 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 25 manager agreed that this would be helpful. We were told that the home employs sixteen staff and that eight support staff are qualified to NVQ II or above which exceeds the National Minimum Standards. At the last inspection we raised issues regarding low staffing levels and as a result the provider has increased staffing. The manager told us that there are now an extra thirty extra hours per week. We looked at the duty rota and found that there are generally four or five support staff on at peak times, although very occasionally this can fall to three staff. The manager states that she is supernumerary but also likes to work alongside staff to help out and keep up to date with residents’ needs. As we have already stated, these staffing levels impact upon residents’ individual needs and preferences with regard to activities and outings. Residents generally go out in groups or in pairs and these opportunities are provided in rotation. All eight residents are highly dependent and require at least one member of staff to support them in the community. This inevitably means that if there are four staff on duty, only two residents are able to go out (together), and two staff remain at home to support six residents. The home has recently received a monitoring visit from the Local Authority contracts unit who have also raised issues over staffing and agreed to carry out reassessments of all residents’ needs in order to review fee levels and funding arrangements. Shortfalls in the duty rota are covered by ‘relief’ staff who also work for Sandwell Community Caring Trust. The manager states that it is usually the same relief staff who work at the home in order to provide consistency of support to residents. Two relatives commented upon the low staffing levels and one person said: “they need to use less temporary staff”. The manager acknowledges that more male staff are needed to provide support to the three male residents; currently there is only one male member of staff employed. We looked at a new member of staff’s personal file to examine whether there are robust recruitment and selection procedures in place. We were pleased to find that all the required pre-employment checks had been undertaken. We also saw employment checks for a relief member of staff which were also all up to date and correct. 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. We discussed with the manager how there will shortly be changes to these qualifications and in line with the common induction standards there 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 26 will be a new ‘induction award’ for providing support to people with learning disabilities. The majority of staff have received training in equality and diversity. We looked at supervision records and found that staff are receiving regular and structured supervision. Any issues identified with practice are swiftly dealt with by the management team. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home that is managed by a competent and skilled person. Quality assurance systems require further improvement in order for all people to be confident that their views underpin the development of the home. There are systems in place promote residents’ health and safety. EVIDENCE: Ms. Whitehouse has been in post for a couple of years as registered manager and runs the home in the best interests of residents. We saw that she has a very good rapport with both residents and staff and demonstrates excellent understanding of the complex needs of people who have a learning disability. The manager keeps herself up to date with changing legislation and has recently undertaken training in the Mental Capacity Act 2005. She is currently 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 28 completing her registered manager’s award. There are regular staff meetings and formal supervision sessions for staff. During interviews staff said that they felt supported by the management team at Pedmore Walk. One staff member told us: “she’s brilliant!”. Comments from relatives and professionals include: “Pedmore walk is a home that is run very well by all the staff there”. “Pedmore Walk provides a homely atmosphere and is a pleasant small residential home for service users. The staff are friendly and the unit is well run”. The manager told us that the quality assurance system has not yet been formally established. Although we did see that there are regular audits undertaken by the management team. The operational manager visits on a regular basis to carry out checks but the last monthly report was dated March 2007. The regulations require that reports from monthly visits are provided and copies are given to the manager and the Commission for Social Care Inspection (CSCI). Staff personnel files continue to be held at the provider’s head office and as a result information required by the Care Homes Regulations 2001 are not held on the premises. Upon request this information was promptly retrieved from the head office for both permanent and relief staff and made available for inspection. Guidance was issued by CSCI in November 2005 regarding retention of staff records and in particular criminal record bureau (CRB) disclosure checks. The provider needs to decide whether this is applicable to their organisation and make applications for a formal written agreement to CSCI to retain documents at their head office in line with this guidance. We looked at a sample of maintenance and service checks and found these to be up to date. We made requirements at the last inspection visit which we saw had been addressed. For example, lifting equipment has been serviced and inspected, and an assessment has been undertaken with regard to one resident’s moving and handling. There are now regular checks in place for hoists, bedrails and wheelchairs. These are not explicit with regards to what parts of the equipment are checked, but the manager told us she was very confident that staff were very aware of what to look for when carrying out these safety checks. We saw that fire safety equipment and the alarm system had been serviced and there are regular fire safety evacuation drills involving both staff and residents. The fire safety risk assessment has been expanded by the manager and is relevant to Pedmore Walk. There is monthly testing of water temperatures. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 29 We found that food hygiene practice was good and the home has been awarded a ‘Gold award’ by the local Environmental Food Safety officer. Staff have undertaken mandatory training. We looked at the training matrix and sampled training certificates which tallied upon checking. Some training is out of date but the manager was able to demonstrate that staff were already booked on refresher training. There was one concern we raised with regard to a member of staff who has received no training in moving and handling but who is involved in assisting residents to transfer using lifting equipment (along with trained staff). The staff member had been booked on training but had failed to attend. The manager immediately arranged for the member of staff to be booked on a forth coming training course. Fire training has been carried out in-house and externally. This is also now due to be repeated and the manager told us that this would be carried out in due course. 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 30 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 3 X 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 31 No 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 YA33 Regulation 18(1)(a) Requirement To ensure that there are sufficient numbers of staff on duty in order to meet all of the individual needs and preferences of residents, particularly with regard to their welfare and undertaking a range of stimulating activities and community based outings. Timescale for action 01/09/07 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 YA1 Good Practice Recommendations The statement of purpose should clearly set out the physical environmental standards met nor not met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2. It should also clearly set out how the layout of the building does not fully meet all of the needs of people who have a physical disability. To fully complete and establish a care plan regarding the management of one resident’s challenging behaviour and DS0000004794.V336616.R01.S.doc Version 5.2 Page 32 2. YA6 34 Pedmore Walk 3. 4. YA9 YA17 include recommendations made by the psychologists. To continue to develop risk assessments and ensure that they include risks associated with using wheelchairs. To consider introducing ‘taster’ sessions for residents to experience different food types. To review the menu plan to see if it can be made more seasonal. 5. YA20 To consider introducing a pictorial menu plan. To consider introducing a procedure for auditing and balancing medications which are not received on a monthly cycle in the monitored dosage system such as PRN medicines. To ensure that any medication taken out of the home by residents (either going on holiday or to visit their families) is fully checked and recorded and this process is repeated upon their return. 6. 7. YA23 YA24 It is recommended that if restraint has to be employed, that the length of time that this is carried out is fully recorded as well as debriefing of residents and staff. To complete refurbishment and redecoration of the remaining 5 bedrooms. To repair all doors and paintwork which has been damaged by wheelchair use. To continue to pursue plans to identify and relocate to a more suitable building in order to be able to provide residents who have a physical disability with more independence and dignity. To consider fitting a wash hand basin in the laundry room. To carry out and include regular deep cleaning of the carpets on the cleaning schedule. To consider providing staff with accredited training in physical interventions, for example: non-violent physical crisis intervention (NVPCI) training. To consider providing staff with training in tissue viability, Parkinson’s disease and refreshing training in understanding and managing challenging behaviour. To attempt to employ more male support staff. To ensure that induction and foundation training is provided by an accredited Learning Disability Awards Framework (LDAF) trainer. DS0000004794.V336616.R01.S.doc Version 5.2 Page 33 8. YA30 9. YA32 10. 11. YA33 YA35 34 Pedmore Walk 12. YA39 To establish an effective quality assurance system, which includes feedback from residents, staff, visitors and other stakeholders in the community. An annual development plan should be established based on a systematic cycle of planning-action-review. 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 made available for inspection upon request. To obtain and hold information and documents on the premises in respect of persons carrying on, managing or working at a care home as listed in Schedule 4 of the Care homes Regulations 2001. (Or to make a formal request to CSCI to retain documents at head office and obtain approval in line with guidance issued in 2005). 13. YA41 34 Pedmore Walk DS0000004794.V336616.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V336616.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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