Inspection on 22/11/05 for 34 Pedmore Walk

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 15/06/06

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 Announced Inspection 22nd November 2005 09:00 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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.V259444.R01.S.doc Version 5.0 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.V259444.R01.S.doc Version 5.0 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.V259444.R01.S.doc Version 5.0 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 7th July 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 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. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.00 a.m. and 6:30 p.m. by two inspectors. 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: case tracking, formal interviews with the manager, deputy manager, and two support staff who were on duty. There was also a tour of the premises. A visiting relative was also interviewed. All residents (with one exception) were at their day centres during the day time but were met by inspectors in the morning and later in the afternoon. Formal interviews were not appropriate therefore inspectors relied upon observations of body language, eye contact, gestures, responses and other observations of interaction between staff and service users. A number of records and documents were also examined. Feedback was received from four relatives who completed questionnaires. One resident also completed a pictorial questionnaire with assistance from their family member. Service users appeared comfortable in their surroundings and the home presented a relaxed atmosphere. The overall inspection findings confirmed that staff are maintaining high standards of care and are making genuine efforts to meet any outstanding requirements. Pedmore Walk is a home that provides care for persons who may have profound and multiple learning disabilities and other associated complex needs. A number of standards were examined at the last inspection and this report should therefore be read in conjunction with the previous inspection report to give an comprehensive overview. The inspectors were made to feel very welcome and would like to thank service users and staff for their hospitality and co-operation during the visit. What the service does well: There is an extremely dedicated staff group who are well qualified and competent; they provide a continuity of care for residents in a patient and caring approach. For example, all staff attend celebrations even when not on duty in order to ensure that residents experience the best time possible. There was lots of laughter and positive interaction through out the whole inspection. Concentrated efforts are made by staff to provide a stimulating environment for residents to lead enriching lives. Families are welcomed and actively involved in participating in residents’ lives. All relatives commented that they kept up to date with important information and expressed satisfaction with the overall care provided. Comments included “it is a lovely home and the staff are all so helpful, caring and friendly”. Residents are encouraged to participate in exercising control over their daily routines and overall delivery of care. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 6 Meals are nutritious and well balanced. All bedrooms are individually decorated and furnished and reflect residents’ personal tastes and characters. The premises was warm, tidy and clean through out. The practice in relation to the administration of medication ensures residents receive medication safely. What has improved since the last inspection? What they could do better: The care planning system requires improvement as it does not provide staff with easy accessible information nor does it identify aims or goals. Risk assessments also need to be expanded to ensure that all potential risks to residents’ safety and wellbeing are fully assessed and controlled. On occasions staffing levels are having an impact upon residents’ activities and outings and these need to be reviewed. 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. The provider recognises this shortfall and is looking at building an alternative premises. However plans are in the very early stages. There was a very serious concern identified in respect of the rear entrance to the premises which was found to be unsafe due to broken and uneven paving slabs which requires immediate attention. Recruitment and selection procedures for new staff do not offer suitable safeguards and protection for service users. Immediate requirements were issued to address these very serious shortfalls and to take appropriate action. At the time of writing this report the manager had already started to make improvements. This together with the environmental issues are disappointing findings to what otherwise is an excellent service. It is reassuring that the provider is keen to meet with the Commission for Social Care Inspection to look at ways forward in overcoming issues identified. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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.V259444.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not evaluated. EVIDENCE: These standards were assessed at the last visit. Progress was monitored towards outstanding requirements at this inspection. It was pleasing to see the efforts made by staff in producing an informative and creative service user guide which is solely aimed at providing information to residents in an informative style using photographs. Some additions have been made to the statement of purpose but further details are needed with regard to how the home is complying (or not), with specific standards in relation to the environment. There have been no new admissions to the home since the last visit. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 10 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 and 9 The system for care planning still needs improvement as it does not provide all staff with easy access to information necessary in providing the care required by service users. Continued progress is being made however in assisting residents to participate in making their wishes known with regard to care delivery. 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: These standards were assessed at the previous inspection but were reevaluated at this visit. As before, case files contain a wealth of information but this constitutes a needs assessment rather than a plan as to how care will be delivered with appropriate goals, objectives and actions in the form of guidelines for staff. The organisation has attempted to address this issue and new proformas have been devised. These have yet to be fully implemented and completed by staff, as a result an assessment as to the effectiveness will be undertaken at the next visit. Initial impressions are that these may need to be expanded in order to be wholly efficient. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 11 It is reassuring to see that staff are continuing in their excellent efforts to introduce a person centred planning approach. Essential life style plans are in place for the majority of service users. Staff have worked hard to encourage participation from significant people such as family and friends which together with the service user has built up complete pictures as to how residents wish to be supported. This is commendable. On examination risk assessments still require improvement. Since the last inspection staff have completed more detailed risk assessments with regard to wheelchair use, but these still require further additional information, for example with regard to the maintenance of the equipment and risks associated with posture belts and adjustment. There are a range of activities and health care issues which have not been risk assessed. For example, one resident’s case file stated that food has to be cut up because of the risk of choking but there was no corresponding risk assessment. There were details in the case file that the resident was deemed to be high risk of developing pressure sores but again no corresponding risk assessment giving details as to control measures which are in place. For example, pressure relieving equipment and clinical guidance as to changes in position during the night time. A resident with occasional challenging behaviour (self injury) did not have a risk assessment in place. Risk assessments need to be developed with regard to travel on the passenger lift. As already stated all aspects of residents’ daily living which pose a risk must be assessed. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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 Service users are assisted to participate in a range of leisure and social activities in the home and in the community, which is supportive in helping them lead meaningful lives. However, staffing levels can impact upon this area of care which needs review. Staff fully support residents to keep links with their families thereby ensuring important relationships are maintained. Daily routines are operated on the principles of choice and respect. The home provides a well balanced diet offering choice and variety. EVIDENCE: Examination of weekly activity plans and evaluation sheets confirmed that a wide range of stimulating activities and therapies are provided. For example residents enjoy reflexology sessions provided by a professional reflexologist. The home has a sensory and relaxation room which is suitably equipped. All residents attend full time external day care provision (with one exception) during the week. It was reassuring to hear from staff that they had asked for a reduction in one resident’s attendance at their day centre as they were appearing too tired on their return. On the evening of the inspection service users were participating in ‘pampering sessions, foot spas’ (which they were 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 13 clearly enjoying), and some were watching television. There is a four weekly activity programme with different activities identified for residents during the evening and at weekends. These are rotated as residents usually undertake certain activities in pairs. There is an excellent evaluation programme for all activities. On case tracking it was clear that this is an effective system. For example, one resident had been noted that they appeared not to enjoy foot spa sessions; it was pleasing to see that the activity plan had been accordingly updated with this information. Residents participate in community activities on a regular basis. For example, during October 2005 residents had been on shopping trips to a variety of locations, they had gone on an outing to see Blackpool illuminations, went out for meals and also been on walks. There is however one issue which does need addressing. Staff need to be more careful in ensuring daily records are maintained on activity plans. On examination of records it was confirmed that planned activities are cancelled on a regular basis due to insufficient staff. During interviews management stated that although there are four staff on duty at peak times, there are three evenings a week (and two evenings on the subsequent following week) where there are only three rostered staff on duty. As a consequence planned activities do not always take place as staff are busy with other duties. Staff who were interviewed confirmed that they ‘could really see a difference’ when there are four staff on duty during the evenings. Two out of four relatives commented that they did not feel there were sufficient staff on duty. One relative who was interviewed said that she felt more outings had taken place in the past because there were more staff on duty. This requires review. All relatives who responded via feedback questionnaires confirmed that they were made to feel welcome by staff and could visit their family member in the privacy of their bedroom if they wished. Social events are organised throughout the year to involve families. Several Christmas events are being planned one of including one where the staff, service users and family have a meal out at the local pub. The dedication and commitment of the staff is shown when last year most staff attended the meal even if they were off duty and, as it was late returned to the unit to assist the service users to bed. Families are also welcome to spend Christmas day at the unit if they would like to. Daily routines actively promote independence and decision making. For example on the day of the inspection one resident had chosen to have a lie in until after 10:30 a.m. as they did not have to attend their day centre. It is recognised that residents cannot operate bedroom door locks or open their own mail and this has been discussed with outcomes included in individual service user plans. One resident who had completed their feedback questionnaire confirmed that they could keep their own private items secure and felt that staff treated them well. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 14 During the visit the inspector spoke to three members of staff who demonstrated a clear knowledge and understanding of the service users’ nutritional needs. It was evident through observation and discussion that wherever possible service users are given a choice. Small trial portions give choice of food and then depending on the reaction from service users the staff determine whether they appear to like it. Cultural foods and special diets are also catered for. Staff informed the inspector that although most service users are unable to speak they are able to make there feelings known and staff were very perceptive of their individual body language. It is evident that balanced diets and healthy eating are encouraged an example was given if one service user who has been off her food and only likes sweet things, she was given apple sauce with her Sunday roast to try to encourage her to eat a balanced diet. There are menus available which cover the three main meals and supper; these always reflect the balanced diet that was discussed by staff. However, more detail and variety must be given on menu sheets particularly with regard to breakfast which currently states that this consists of toast and cereal, a cooked breakfast such as eggs on toast etc. would be a nice addition at weekends. Service users can eat separately if the choose, one service user often chooses to do this, but main meals are generally held together. Breakfast times are flexible and residents can get up when they choose if they are not going to the day centre. Individual records of meals taken are kept in care files. Staff assist service users and during the inspection it was observed that families also participate in assisting their relative to eat. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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): 20 The systems for administration of medication are good with clear and comprehensive arrangements being in place to ensure service users’ medication needs are met. Only slight improvements are necessary to ensure all practices comply with professional guidance. EVIDENCE: Standards with regard to health care were fully evaluated at the last inspection. Progress was monitored towards meeting outstanding requirements. Case tracking confirmed that staff are maintaining good standards with regard to swiftly recognising and dealing with any potential health complications. All relatives commented that they were happy with the overall care provided. Since the last inspection staff had discussed with the general practitioner (G.P.) the requirement to refer residents for audiology checks. It has been agreed that referrals will take place if staff notice any deterioration or impairment in residents’ hearing. The inspector has suggested that the annual health care checks undertaken by the G.P. could also encompass this aspect. As requested, there are details in individual case files with regard to screening for breast, testicular and cervical cancer. Staff make visual checks on a regular basis when assisting with personal care and enter outcomes in daily 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 16 records (although this strategy needs to be included in the care plan itself). As requested discussions have taken place with the G.P. with regard to invasive screening and capacity to consent. The manager needs to ensure that outcomes are recorded in all service user plans. There were a couple of new items identified through case tracking. Staff are having difficulty in accessing external resources to ensure residents are weighed on a monthly basis. Weight checks were last undertaken in April 2005. The inspector provided further information with regard to alternative measurement tools. The need for residents to undergo annual eye tests as opposed to two yearly was also discussed. There are very good procedures relating to the control and administration of medication as confirmed through observations of practice and examination of records and the drugs trolley. The drugs trolley was found to be clean and tidy with external and internal medication held separately. There are good procedures relating to ordering medication and checking drugs on arrival at the home. The pharmacist regularly undertakes audits and gives advice where necessary. Staff are attempting to access suitable accredited training but in the meantime have undertaken training with the pharmacist. Medication administration record (MAR) sheets are being accurately maintained. There are a couple of new items which require attention. During interviews a member of staff stated that on occasions medication was given to some service users with food to ease ingestion. On first impressions this sounded like covert administration practice but on further discussions management stated that drugs were not mixed in with food or hidden but some residents struggled with the number of tablets they were expected to digest. As a compromise a requirement has been made for a written protocol and procedure to be established with regard to individual named residents and to be ratified (and signed) with the G.P. and pharmacist (particularly as some tablets may react to certain food stuffs). A copy must be held on individual case files. Any other items discussed during this inspection are contained within the Requirement section of this report. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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): These standards were assessed at the previous inspection. EVIDENCE: Progress was monitored at this visit towards addressing outstanding requirements. It was pleasing to see that all items previously identified with regard to management and recording of residents’ finances, had received appropriate action. The vulnerable adult abuse policy required expanding at the last inspection and this document was said to be with senior management for review. Case tracking revealed a couple of discrepancies with regard to residents’ finances. Although there are excellent procedures in place for auditing monies in the safe and maintaining records by management, there are a couple of areas where improvements need to be made by staff who are assisting service users with the management of their personal allowances. For example, one resident had been inadvertently charged for a sandwich and drink when on an outing on 12 November 2005. As this was a replacement meal staff should have used petty cash to pay for this food. Whilst the receipt had been highlighted in a marker pen which according to the manager was to denote that monies were to be reimbursed, upon checking, this had not taken place. Another issue identified was with regard to record keeping. On 12 November 2005 staff had taken out money for one resident to buy some shopping, this had not been spent and had been returned to the safe. However, the individual personal record had not been updated and as a consequence the balance was incorrect. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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): These standards were fully assessed at the last inspection. EVIDENCE: Progress was monitored at this visit to determine action towards meeting outstanding requirements. It was pleasing to see that the conservatory had now been installed with suitable heating/cooling systems and is now more comfortably furnished. Voiles are now covering the windows however despite the efforts of the manager to improve standards, the carpet is still badly stained ands needs replacing. Some repairs have taken place with regard to damaged plasterwork although there is still some outstanding redecoration required. The manager stated that quotes had been obtained to replace worn carpeting and furniture. As identified at previous inspections the building does not lend itself well to promoting independence for people with physical disabilities with a number of shortfalls mainly in respect of space and equipment. One resident commented that the communal lounge area is too small to accommodate all wheelchair users comfortably. Whilst it is reassuring that the provider acknowledges this unsuitability and proposes to build alternative accommodation; plans are still in the very early stages according to management and on examination of the draft business plan. More detailed proposals with timescales need to be 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 19 provided to the Commission for Social Care Inspection and will be discussed at a forthcoming meeting. There were serious concerns identified with regard to the patio area to the rear of the premises. This area was identified as requiring attention at the previous inspection, however there has been a deterioration over the last few months resulting in this area becoming unsafe. The premises is accessed mainly by service users via the minibus by the rear entrance. There were a number of uneven paving slabs some which had become broken making this a high risk area in respect of slips, trips and falls. This is also a fire escape route. An Immediate Requirement was made to address this issue. Please see the Requirement section of this report for any other items discussed during this inspection. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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, 34 and 35 There is a competent and well qualified staff group offering consistency of care for service users. Recruitment and selection procedures do not offer enough safeguards and protection for residents. Induction programmes need expansion to give staff more underpinning knowledge regarding the specialist needs of service users. EVIDENCE: Eleven of the existing seventeen staff team are qualified to NVQ II or above; this exceeds the national minimum standards which is commendable. Staff interviews and observation of practice through out the inspection confirmed that this is a competent and skilled team. The majority of staff have worked at the home for over two years; there are a number of staff who have been employed for five years or more. Some specialist training in respect of tissue viability has yet to be accessed. Recruitment and selection of new staff is undertaken centrally at the providers’ headquarters. Staff personnel files are still held centrally (see further comment in standard 41). These were made available on the day of the inspection. Examination identified a number of serious concerns and discrepancies. For example, there were gaps in employment history with no written explanation contained within the individual staff file. Two written references had not been obtained for one new member of staff. A verbal reference had been taken which is not appropriate and does not meet the 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 21 requirements of the Care Homes Regulations 2001, Regulation 19. This member of staff had commenced employment on 18 July 2005. It was recorded that the referee ‘had no problems’, this was not dated or signed, and in any event this information is not sufficient enough to make a judgement as to the candidate’s suitability. Neither of the 3 staff who were recently employed had a recent photograph on their personnel file and one person only had a P45 as a form of identification. Another reference for one staff member had been supplied by the worker themselves and was addressed ‘to whom it may concern’. This is not appropriate practice. It was extremely concerning to find that two staff had been appointed without a criminal record bureau (CRB) disclosure and Protection of Vulnerable Adult (POVA) check. The guidance issued by the Department of Health in the Protection of Vulnerable Adults Scheme states that: ‘in the normal course of events, from 26 July 2004, providers of care must not employ people in care positions until satisfactory results from CRB disclosures and POVA checks have been issued. However, in very exceptional circumstances, where service users may be placed at risk because providers are having difficulty in recruiting sufficient staff, such providers may begin to employ people in care positions without having to wait for the full results of the CRB disclosure. In order to employ someone in a care position pending the results of a CRB disclosure providers of care must carry out the required rigorous pre-employment checks, have applied for a CRB and POVA check, and have applied for and received a satisfactory result from, a POVA First check (as required by the Care Homes Regulations (Amendments) 2004, Regulation 19). In addition other criteria must also be complied with as required by Care Homes Regulations 2001, Regulation 19(11). It is also expected that providers will carry out a written risk assessment prior to the appointment of staff, pending the receipt of a satisfactory CRB and POVA check. This must be discussed and forwarded to the Commission for Social Care Inspection, prior to their employment. Immediate Requirements were issued to address shortfalls. Although there is a comprehensive induction programme in place for new staff; there has been no progress towards providing staff with induction and foundation training which meets the requirements of the Sector Skills Council and is provided by an accredited Learning Disability Awards Framework facilitator. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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): 41 and 42 Service users’ rights and best interests are not safeguarded by the home’s record keeping policy. Some health and safety shortfalls were noted in relation to the premises thereby jeopardising residents’ safety, however other aspects of health and safety are well promoted. EVIDENCE: The registered provider is still holding staff personnel files centrally which does not comply with the requirements of the Care Homes Regulations 2001, 17(2). At previous meetings a compromise was agreed but this was dependent upon recruitment and selection procedures being found to be robust. This inspection has identified shortfalls in practice and procedures. New guidance has recently been issued by the Commission for Social Care Inspection regarding record keeping which will be discussed with the provider at a forthcoming meeting. Other discrepancies already identified in respect of record keeping are with regard to financial management. Staff are also not always signing their names when making entries onto service user plans. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 23 Records and checks have been received with regard to visiting professionals as previously required. It was pleasing to see progress is being made by management with regard to seeking feedback from relatives and expanding quality assurance systems. Health and safety practice is generally good (with the exception of the serious concern already mentioned in relation to the premises). Maintenance and service records were sampled and found to be up to date. Improvements have been made with regard to more consistent checking of the fire alarm system. Some risk assessments still require updating and were said to be with senior management. Regular checks on equipment such as wheelchairs, bedrails and hoists take place but as discussed, these need to be recorded. There is a strong emphasis on mandatory training for staff. As a result the majority of staff have received the required statutory training which is excellent practice. There is good food hygiene practice. Food temperature, records and cleaning routines are well maintained in the kitchen. Food is stored and labelled appropriately. There are some outstanding requirements which still need attention. For example, there needs to be an individualized business and financial plan for the home. The service provider is still failing to comply with the Requirements of the Care Homes Regulations 2001, Regulation 26. Although a senior manager from the organisation is visiting on a regular basis, a written report of the conduct of the home is neither provided to the manager or the Commission for Social Care Inspection. This must be addressed. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 4 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 1 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 34 Pedmore Walk Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X X X 1 2 x DS0000004794.V259444.R01.S.doc Version 5.0 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6 Requirement Timescale for action 01/04/06 2. YA6 15(1) 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 01/04/06 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 recognised format such as essential life style planning and life story books. (Previous 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 26 3. YA9 13(4)(c) 4. YA14 16(2)(n) timescale of 1/1/05 is partly met). 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 not met). To ensure that weekly activity planners are more consistently completed by staff on a daily basis. 01/01/06 01/02/06 5. YA17 16(2)(i) 6. YA19 12(1)(a) To undertake a documented review of staffing levels to ensure that they are sufficient in order for all service users’ chosen activities to be facilitated on a more regular basis. To undertake a review of the 01/02/06 menu to expand the choice for breakfast (for example at weekends). 01/03/06 To make the following improvements with regard to healthcare monitoring and recording: 1) The Home must introduce a formal procedure in care plans for the monitoring of service users health with regard to potential complications such as breast screening, testicular screening through observational checks. (Previous timescale of 1/1/05 is partly met). 2) To undertake a documented discussion with the G.P. regarding service users lack of capacity to consent to invasive screening such as mammograms and cervical smears. Outcomes to be included in individual case 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 27 plans. (Previous timescale of 1/6/05 is partly met). 3) To pursue annual ophthalmology checks for all service users. 4) To undertake monthly recorded weight checks for all service users using alternative measuring and screening strategies (if necessary seeking advice from the community dietician). 7. YA20 13(2) 1) To review and update the 01/02/06 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 either obtain written consent from individual service users with regard to administration of medication or to discuss as part of a multidisciplinary team at forthcoming reviews and record outcomes in individual service user plans. 4) To establish a written policy and procedure regarding the administration of medication with food to three named service users. To obtain written 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 28 consent and advice from general practitioner and pharmacist. To retain copies on service user plans. 5) To ensure that two staff initials are obtained to confirm any handwritten additions or changes are made to instructions on medication administration record (MAR) sheets. To expand the vulnerable 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 improve recording keeping with regard to service users’ personal finances and ensure that staff promptly record when monies are returned. To progress plans to reimburse a named service user for the cost of a replacement meal which was charged in error on 12 November 2005. 9. YA24 23(2)(p) To undertake the following improvements to the premises: 1) To provide the Commission for Social Care Inspection (CSCI) with a written programme of refurbishment together with timescales for completion. (Previous timescale of 1/9/04 is partly met). 3) To explore the lack of water and low water pressure in first 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 29 8. YA23 13(6) 01/01/06 01/02/06 floor bathroom and carry out required repairs. (Previous timescale of 1/9/04 is not met). 4) To replace all stained carpeting in communal areas and bedroom areas. (Previous timescale of 1/11/05 is not met). 5) To replace all worn and broken furniture in communal areas (dining room) and individual bedrooms. (Previous timescale of 1/11/05 is not met). 7) To regrout stained tiling in shower room and clean stained tiling in bathroom. (Previous timescale of 1/11/05 is not met). 8) To replace stained and worn covering on cradle chair. (Previous timescale of 1/11/05 is not met). 9) To replace worn garden furniture. (Previous timescale of 1/11/05 is not met). 10) To clean and repair loose paving slabs on patio area. (Previous timescale of 1/11/05 is not met – due to deterioration this is now an IMMEDIATE REQUIREMENT: 6 December 2005. 11) To remove unsuitable signage in service users bedrooms. (Previous timescale of 1/11/05 is not met). 13) To repair all doors which have been damaged by wheelchair use. (Previous 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 30 timescale of 1/11/05 is not met). 14) To remove staff lockers from the laundry area. (Previous timescale of 1/11/05 is not met). 15) To carry out a written risk assessment with regard to the positioning of a rocking armchair and a wall mirror in one service user’s bedroom. 16) To forward written proposals to the Commission for Social Care Inspection regarding proposals and action required together with timescales for the plans to source a new premises. 10. YA34 13(6) 19 To make the following improvements to recruitment and selection: 1) To cease the appointment of new staff without obtaining all of the required pre-employment checks – Immediate Requirement by 23/11/05. 2) To carry out written risk assessments for 2 staff who have been appointed without awaiting the return of a satisfactory criminal record bureau disclosure or Protection of Vulnerable Adult (POVA) check or a POVAFirst check. To identify and undertake control measures to minimize risks to service users of abuse. Immediate Requirement by 23 November 2005. 3) To collate all of the required 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 31 23/11/05 pre-employment checks for 3 staff members who have been appointed without the required checks and documentation. Immediate Requirement by 23 December 2005. 4) To obtain POVAFirst checks for 2 staff who have been appointed without the appropriate checks within three days and forward to the Commission for Social Care Inspection. Immediate Requirement by 28 November 2005. 5) To ensure that if staff are appointed in extenuating circumstances without a criminal record bureau or POVA check – that a POVAFirst check is obtained and received, and that a written risk assessment is forwarded to the Commission for Social Care Inspection and discussed prior to appointment of the member of staff. 1) To provide induction and 01/03/06 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. (Previous timescale of 1/1/05 is not met) 2) To provide training for staff in equal opportunities and disability equality training. (Previous time-scale of 1/1/05 is partly met). To ensure that the manager is qualified to NVQ IV in management by 2005. (P DS0000004794.V259444.R01.S.doc 11. YA35 18(1)(c) 12. YA37 18(1)(c) 01/01/06 34 Pedmore Walk Version 5.0 Page 32 12. YA39 24 13. YA41 13(6) 19(1)(b) 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). To obtain and hold 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). To ensure that when making entries into individual service user plans that staff sign their name. To review and expand the Legionella risk assessment. (Previous timescale of 1/11/05 is not met). 01/04/06 01/02/06 14. YA42 13(4)(c) 01/02/06 15. YA42 To establish regular and recorded maintenance checks on all wheelchairs, hoists and bedrails (to supplement periodic servicing). 23(4)(a)(v) To review and expand the fire 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). 13(4)(c) To provide all staff with training in how to manually operate the lift mechanism in the event of a breakdown; this must be fully recorded. – (Not assessed at this inspection) To establish written procedures for the lift escape system and 01/02/06 16. YA42 01/04/06 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 Page 33 disablement of the lift by staff in order to safeguard service users and staff from containment. (Not assessed at this inspection) 17. YA43 25 The Manager must ensure that the business and financial plan for the home is available for inspection. (Previous timescale of 20/5/04 is partly met). 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). 01/02/06 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. 2. 3. 4. Refer to Standard YA23 YA30 YA32 YA43 Good Practice Recommendations To ensure that all staff receive training in vulnerable adult abuse. To consider fitting a wash hand basin in the laundry room. To consider providing staff with training in tissue viability awareness To ensure that the actual address of the Home is included on the Public Liability Insurance cover certificate or schedule. 34 Pedmore Walk DS0000004794.V259444.R01.S.doc Version 5.0 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: 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.V259444.R01.S.doc Version 5.0 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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