Inspection on 18/07/07 for 34 Walsall Street

This inspection was carried out on 18th July 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Walsall Street 20/01/09

34 Walsall Street 05/02/08

34 Walsall Street 05/07/06

34 Walsall Street 07/11/05

34 Walsall Street 23/05/05

34 Walsall Street 18/01/05

34 Walsall Street 13/09/04

34 Walsall Street 27/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 34 Walsall Street Willenhall Walsall West Midlands WV13 2ER Lead Inspector Dawn Dillion Key Unannounced Inspection 18th & 19 July 2007 10:00 34 Walsall Street DS0000020850.V346343.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 Walsall Street DS0000020850.V346343.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 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Walsall Street Address Willenhall Walsall West Midlands WV13 2ER 01902 632211 01902 632211 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) Swan Village Care Services Limited Vacant post Care Home 5 Category(ies) of Learning disability (3) registration, with number of places 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users with physical disability aged 18-65 years to be admitted. 5th July 2006 Date of last inspection Brief Description of the Service: 34 Walsall Street is a registered care home located in Walsall, West Midlands and provides a service for five people who have a learning disability, of which one person accesses the service on a respite basis. The home is situated in walking distance from Willenhall town, having easy access via public transport to Walsall Town Centre. 34 Walsall Street is a large detached property, which comprises of five single occupancy bedrooms, two of which are located on the ground floor, having en suite facility and the remaining three situated on the first floor equipped with a washbasin. Two bathrooms are located on the first floor; there is a stair lift in place, to enable people living in the home to access all facilities. A lounge area is provided on the ground floor, equipped with essential furnishings and fitments, where individuals are able to relax or socialise with other people living in the home. The home also provides a small dining area, a domestic style kitchen and a laundry area. People using the service also have access to a private garden area at the rear of the property. Very limited car parking is available within the garden area. Staffing is provided on a 24-hour basis, to ensure the total supervision and support of people living in the home. People living in the home had access to relevant healthcare services. The fees chargeable for the service provided at 34 Walsall Street are from £544.83p to £1,164.56p per week. Respite care is £1,500.00p per week, for less than a week it is calculated at a daily rate of 1/7th of the weekly rate. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of 34 Walsall Street was undertaken within ten hours over two days. The inspection methodologies that were used, to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, best practices and equality and diversity, entailed the examination of the records and documents relating to the homes policies, procedures and general practices. People that use the service and staff members were interviewed during the process of the inspection, to establish their views of the service provided. A tour of the property was undertaken, to ensure that the environment and systems in operation were safe and suitable in meeting the needs of the people who live in the home. The home does not have a Registered Manager in post; the nominated Manager was not present on the first day of the inspection. Some care practices within the home raised concerns with regards to privacy, a lack of holistic views on equality and diversity and poor menu planning, to reflect the dietary needs, of people requiring specialist dietary requirements due to health, cultural and religious needs. What the service does well: During the process of the inspection staff were observed to interact and communicate with people living in the home in a professional manner. It was pleasing to see that the home had published a number of policies and procedures in appropriate languages and in a pictorial format to promote the understanding of people accessing the service. The home provided sufficient staffing levels, discussions with a number of staff confirmed that training was on going. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The previous inspection report identified concerns relating to the management of people suffering diabetes. It was difficult to collate information to establish how the individuals were supported to manage this illness. Poor menu planning did not promote the health of individuals suffering with diabetes nor evidenced that people’s needs were met with reference to their cultural and religious needs. One toilet was located on the ground floor, which was allocated for staff use only. Bedrooms located on the ground floor were equipped with en suite facilities. One female accessed respite service on a weekly basis and was allocated a bedroom on the first floor. Due to limited mobility, staff assisted this individual to access a male persons bedroom on the ground floor, to use his en suite. No consideration was given to the lack of privacy for the individual accommodating this bedroom and the indignity of this female having to access this man’s bedroom to use his en suite. A gate had been fitted to a bedroom door. Discussions with the Senior Support Worker confirmed that this had been fitted to prevent the individual from falling down the stairs. No consideration had been given to the extent of injuries that may be caused if the person climbed over the gate, or on the infringement of her human rights and her freedom of movement. There was a lack of recognition of the cultural and religious needs of all people living in the home. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 7 The home was in general need of maintenance and furnishings provided were worn and non-functional in some areas. 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 Walsall Street DS0000020850.V346343.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 Walsall Street DS0000020850.V346343.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, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of the homes Statement of Purpose and Service User Guide. People who may wish to access the service at the home were provided with relevant information, to enable them to establish whether the service and provisions would meet their assessed needs. EVIDENCE: The homes Statement of Purpose and Service User Guide provided relevant information relating to the service and provisions provided within the home. These documents were published in plain English, Punjabi and pictorial to promote the understanding of people using the service. Discussions with the Senior Support Worker confirmed that there had been no new admissions to the home since the last inspection. The homes admission process incorporated a Care Management Assessment (Pre Admission Assessment), people wishing to access the service were also able to visit the home prior to admission, giving them the opportunity to view the premises, 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 10 meet the people living in the home and the staff team. Where appropriate the individual would also be able to have an overnight stay. One bedroom on the first floor was allocated for respite stay; the home provided a regular respite service to one person. The Senior Support Worker informed the Inspector that due to the person’s limited mobility, they had difficulty accessing the toilet and bathroom area. The registered person should ensure that a comprehensive assessment of this individual is undertaken to ensure their safety, welfare, privacy and dignity. 34 Walsall Street DS0000020850.V346343.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 adequate. This judgement has been made using available evidence including a visit to this service. The examination of care plans, risk assessments, discussions with people that use the service, staff members and general observations. Peoples assessed care needs were incorporated within a care plan. The lack of detail focused on the management of diabetes and inappropriate menu planning compromised the standard of care provided. EVIDENCE: Information obtained from the Care Management Assessment provided the foundation for the development of the care plan and risk assessment. Two 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 12 care plans were randomly selected for examination, both contained detailed information, relating to the care needs of the individual and also identified the level of support and assistance the person required to live a full and active lifestyle. The Inspector raised concerns that information relating to two individuals suffering with diabetes was not easily identified within the care plan and it was difficult to establish how their diabetes was being managed. One care plan identified the need for a strict diet but failed to provide the reason why. Discussions with the Senior Support Worker confirmed that this individual was a diabetic. There was evidence that where possible people were actively involved in the development and review of their plan of care. Care plans were reviewed on a monthly basis to reflect the changing needs of the individual. People living at 34 Walsall Street had complex needs with limited or no communication skills. Meetings were undertaken to encourage people living in the home to be actively involved in decision making. The Senior Support Worker informed the Inspector that people living in the home had access to a self-advocacy service. One person living in the home main mode of communication was Makaton, information contained within the care plan identified that, “can get frustrated very easily due to problems with communicating.” It is of concern that staff had not received Makaton training. Risk assessments were in place for the individual, providing information about potential hazards and control measures to ensure that people were able take an informed risk to live a normal lifestyle. 34 Walsall Street DS0000020850.V346343.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Discussions with people who use the service and staff members, general observations and the examination of menus. People who use the service were able to make choices about their lifestyle, however, this was compromised by the lack of holistic view on equality and diversity, poor practices that impinged on the privacy and dignity of people living in the home. Poor menu planning did not promote healthy eating. EVIDENCE: The Senior Support Worker informed the Inspector that the home had limited access to transport of which caused some constraints with accessing social activities within the community. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 14 The home is located in walking distance to Willenhall Town, having easy access to local transport to Walsall and Wolverhampton, with the local bus service providing transport for wheelchairs users. Staff should be encouraged to use these services to ensure that people living in the home have regular community contact. On the day of the inspection two people went out on a shopping trip to Walsall and used the public transport. One person living in the home informed the Inspector that staff assisted her to clean her bedroom and to undertake other daily domestic tasks within the home. She informed the Inspector that she attended the local college undertaking English, maths and that she was actively involved in a selfadvocacy group. She was able to access services in the community independently and on the morning of the inspection, she informed the Inspector that she was going to college for an interview to enrol for further training. She informed the Inspector that, “my dream is to get a proper job with proper money.” One person living in the home accessed day care services three times a week, discussions with another person living in the home and a staff member informed the Inspector of social activities that consisted of outings to Cadbury World, Sea Life Centre, cinemas and shopping trips. One person informed the Inspector of forthcoming holidays to Great Yarmouth and Southport. The home accommodated two people from the ethnic minority group, one who was of Sikh faith and the other a Muslim. Discussions with one person living in the home and the examination of the individuals care plan, confirmed that his cultural and religious needs were being met in accordance to his care plan. The service user guide was also published in relevant languages to promote the understanding of people accessing the service. People living in the home benefited from a mixed cultural staff team, who also spoke the language and were aware of the religious aspects of these cultures. One person informed the Inspector that he was able to visit the temple on a weekly basis, talk in his own language and was provided with meals of his preference. He also informed the Inspector that he enjoyed watching Asian movies and listening to the music but confirmed that another person living in the home objected to this. A positive emphasis was focused on cultural and religious needs of two people living in the home but there was evidently a lack of recognition, that the other people living in the home may also have cultural and religious needs. When the Inspector made enquiries with regards to the cultural and religious needs of other people accessing the service, the Inspector was informed that they were British. To promote equality and diversity there needs to be an holistic approach to ensure that every ones cultural and religious needs are explored. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 15 People living in the home were provided with the necessary support and assistance to access leisure facilities within the community. One person living in the home informed the Inspector that she goes swimming, bowling and attended the Gateway Club and discos. The Inspector raised concerns regarding the lack of emphasis focused on the privacy and dignity of people using the service. During the process of the inspection it was identified that there was one toilet located on the ground floor, which was allocated for staff use only. Bedrooms located on the ground floor were equipped with en suite facility. One female accessed respite service on a weekly basis and was allocated a bedroom on the first floor. Due to limited mobility, staff assisted this individual to access a male persons bedroom on the ground floor, to use his en suite. No consideration was given to the lack of privacy for the individual accommodating this bedroom and the indignity of this female having to access this man’s bedroom to use his en suite. The inspection of the property also identified that a stair gate had been fitted to a bedroom door. Discussions with the Senior Support Worker confirmed that this had been fitted to prevent the individual from falling down the stairs. The risk assessment identified that, “These control measures are not used to restrain X but to prevent her from hurting herself if she leaves her room and falls downstairs.” No consideration had been given to the extent of injuries that may be caused if the individual climbed over the gate, or on the infringement of her human rights and her freedom of movement. There was no nurse call alarm system fitted in the bedroom. With the lack of toilet facilities and the location of the bedroom it was evident that the home was not in the position to meet this individuals needs appropriately to ensure her welfare and safety. Discussions with two people who use the service confirmed that they were able to maintain contact with their family and friends who were able to visit the home at anytime within reason. With reference to meals and mealtimes, the Senior Support Worker informed the Inspector that people living in the home were actively involved in the development of the weekly menu. There were five people living in the home two of who required a special diet in relation to their cultural and religious needs and two other people suffered with diabetes. The examination of the menus identified a lack of a well-balanced nutritional diet, three meals were provided per day with the majority consisting of a high proportion of carbohydrates with very little vegetables incorporated within the diet and no fruit. Albeit one person living in the home informed the Inspector 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 16 that the home met his dietary needs with regards to his culture and religion this was not identified within the menu planning. There was a pictorial menu in place to assist individuals with limited communication skills. There was no emphasis focused on a controlled diet for individuals suffering with diabetes. Apart from 1.5 bags of potatoes there were no fresh vegetables or fruit within storage in the kitchen. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 17 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, 20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The examination of care plans and the homes medication system and practices. The lack of structure the management and support for people suffering diabetes compromised the quality of care provided. The homes medication system and practices ensured that people received their prescribed medication as directed by the General Practitioner. EVIDENCE: Staffing was provided within the home on a 24-hour basis, to ensure that the individual received the necessary supervision. Albeit, that some people living in the home had some element of reduced mobility, there were no requirements for moving and handling. Discussions 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 18 with two people who use the service confirmed that they were able to retire to be bed and awake when they so wished. People that use the service informed the Inspector that they had a key worker. Records that were examined during the process of the inspection evidenced that people had access to relevant healthcare professionals and were linked with the Learning Disability Team. The Inspector raised concerns that information relating to the management and support required, in relation to two people living in the home who suffered with diabetes, was very spasmodic and very difficult to establish the treatment and support the individual was receiving. Poor menu planning also compromised the management of diabetes. The home operated the Nomad monitored dosage system, records relating to the administration, storage and recording of medication was examined and found to be satisfactory. Care plans that were examined provided very little or no information relating to peoples wishes in the event of their death. Albeit that this is a sensitive subject, people should be provided with the relevant support to discuss their wishes of which should be recorded. 34 Walsall Street DS0000020850.V346343.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. The examination of the homes complaint procedure and staff recruitment procedures. People who use the service were able to express their concerns, and have access to a complaint procedure, and were protected from abuse. EVIDENCE: Information relating to the homes complaint procedure was incorporated within the Statement of Purpose and the Service User Guide of which was accessible to people using the service. The home was in receipt of the Safeguarding policies in relation to the relevant funding Local Authorities. Three files pertaining to staff that had recently been recruited evidenced that relevant safety checks were undertaken prior to the commencement of employment, to protect people living in the home from abuse. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The layout and design of the property was not functional to meet the needs of all people accessing the service and also compromised the privacy and general welfare of the individual. EVIDENCE: 34 Walsall Street is situated in Walsall, West Midlands and is located within walking distance from Willenhall town, having easy access via public transport to Walsall Town Centre. The large detached property was in keeping with the local community, the home comprised of five single occupancy bedrooms, two of which were located on the ground floor, having en suite facilities and the remaining three situated 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 21 on the first floor were equipped with washbasins. Furnishings within the bedroom were worn and tired looking with many in a state of disrepair. The grab rail in one en suite had come away from the wall and tiling was broken. The carpet in one bedroom was old and stained. One bedroom was allocated for a respite service, this room was sparse, institutional and the furnishings were old. A single bulb from the ceiling did not have a light shade and the general lighting within this room was poor. Two bathrooms were located on the first floor of which was sparse and institutional, offering no home comforts. One toilet was allocated on the ground floor for staff use only. As previously identified within the contents of this report, one person accessing the service on a respite basis, was identified to have reduced mobility and would use the en suite within another persons bedroom, which was a infringement of the individuals privacy. There was a stair lift in place, to enable people living in the home to access facilities available. A lounge area was provided on the ground floor, this area had recently been painted and fitted with new flooring. Furnishings within this area were old and worn. The home also provided a small dining area, a domestic style kitchen and a laundry area. The laundry was equipped with a washing machine and a dryer; there were no sluicing facilities available. Discussions with the Senior Support Worker confirmed that there was an issue of continence management within the home. The cleanliness of the home was of a reasonable standard with the exception of one bedroom. Discussions with a staff member confirmed that the individual was encouraged to maintain the hygiene standards within the bedroom, however, due to the lack of cleanliness of this room, the home had experienced the presence of mice. People using the service also had access to a private garden area at the rear of the property. Very limited car parking was available within the garden area. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of staff working rotas, staff files and training records. There were adequate staff provided in sufficient numbers to support the people who use the service. EVIDENCE: Three staff members were interviewed during the process of the inspection, all of who confirmed that they were in receipt of a job description and a contract of the terms and condition of employment. A copy of the General Social Care Council code of conduct was available within the home. The examination of training records identified that staff had received the following training within the last two years, medication, food hygiene, health and safety, moving and handling, adult protection, domestic violence, fire 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 23 safety and dementia awareness. The Senior Support Worker informed the Inspector that all staff had received equality and diversity training within the last twelve months. The Senior Support Worker informed the Inspector that seven out of nine staff had completed the National Vocational Qualification, (five level 2 in Care and two level 3 in Promoting Independence). The Inspector raised concerns that the examination of one care plan, identified that one persons main mode of communication was Makaton and staff had not received training within this area. Discussions with the Senior Support Worker and the examination of staff working rotas evidenced that sufficient care hours were provided to meet the needs of people living in the home. The Senior Support Worker informed the Inspector that the home had recently increased the staffing hours during the night, to ensure that one person who lived in the home, that displayed challenging behaviour was provided with additional support and supervision. As previously identified within the contents of this report, the homes recruitment procedure ensured that the appropriate checks were undertaken prior to the commencement of employment to protect people living in the home from abuse. The Senior Support Worker informed the Inspector the home would be commissioning future staff training accredited by the Learning Disability Framework (LDAF). Discussions with staff and the examination of files evidenced that staff received regular supervision sessions. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of structured management to promote equality, diversity, the privacy and rights of the individual, had a negative impact on the quality of the service delivery. EVIDENCE: The home does not have a Registered Manager; the proposed Care Manager was not present on the first day of the inspection. The examination of the homes policies, procedures, discussions with people who use the service, staff members and general observations, identified that, albeit there were some 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 25 positive aspects to the service provided to people living in the home. The lack of an holistic view on equality, diversity, privacy, poor menu planning and the practice of restricting the movement of one person living in the home compromised the quality of care provided to individuals. With reference to quality assurance, the home undertook regular meetings with people that use the service. The Senior Support Worker informed the Inspector that comment cards were distributed to people. There was also evidence of regular visits to the home by senior management, to monitor the service delivery, information within one of these reports, identified confidential information, pertaining to a staff member which should be addressed within supervision and recorded and stored more appropriately. Records and systems that were examined regarding the health, safety and welfare of people accessing the service identified the following: Water temperature monitoring identified temperatures of between 37oC to 46oC; the last recorded test was on 27/06/07. Gas appliances and system were serviced on 31/01/07. Portable appliance testing (PAT) was undertaken on 30/11/06. Records evidenced that staff had undertaken fire awareness training on 27/11/06. The fire risk assessment was more of an audit and did not provided sufficient information relating to control measures for identified potential hazards. The fire alarm system was checked on a weekly basis, the last recorded check was on 13/07/07. The last recorded fire drill was on 23/02/07. The cleanliness within the identified bedroom compromised the health and safety of other people living in the home and the Registered Person should ensure that appropriate measures are taken to address this area of concern. One person living in the home smoked, the dining room had been allocated as the smoking area. The Senior Support Worker informed the Inspector that the home were currently in the process of arranging a suitable facility outside the building for this individual to smoke in. The current situated for the other people living in the home and staff was unacceptable having to inhale the smoke and to dine in a smoke filled area. The registered person should ensure that an audit is undertaken on all wardrobes to ensure that they are secured to the wall. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 1 27 1 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 1 16 1 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 2 1 1 2 3 X 2 X 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 27 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 YA17 Regulation 16(2)(i) and 12(1)(a) Requirement Timescale for action 30/08/07 2. YA27 23(2)(j) 3. YA16 21(1) and 12(4)(b) The lack of a well balanced nutritional diet, compromised the health of individual’s suffering with diabetes and also failed to meet the cultural and religious dietary needs of some people living in the home. The registered person should take the appropriated action, to ensure that people are provided with a suitable diet in accordance to their health, culture and religious needs. Three people living in the home 25/09/07 did not have access to a toilet on the ground floor. The registered person is required to ensure that appropriate numbers of toilets are provided within the home and that they are accessible to people using the service A lack of an holistic approach in 25/09/07 relation to equality and diversity compromised the service provided to all people living in the home. The registered person should take the appropriate measures to ensure that there is a 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 28 4. YA16 21(1) recognition of the cultural and religious needs of all people accessing the service. A gate had been fitted to a bedroom doorway; this restricted the freedom of movement of the individual. The registered person should take the appropriate action to ensure that the identified persons human rights are respected and to ensure her health, safety and welfare. 30/08/07 5. YA30 23(2)(k) The lack of a sluicing facility compromised management of infection control. 30/10/07 6. YA24 23(2)(c) and 16(2)(c) The registered person is required to provide suitable systems to prevent cross contamination. 25/09/07 Furnishings within the home were old, worn and many were in a state of disrepair. The registered person is required to take the appropriate actions to ensure that people living in the home are provided with suitable and functional furnishings. The grab rails within one en suite had come away from the wall and tiling was broken. The registered person should ensure that the person occupying this room is provided with suitable aids to assist with their mobility. (Concerns relating to the general maintenance, decor was also identified within the last inspection report. The timescale was 31/08/06; this will be 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 29 7. YA42 13(4)(a) identified within the Management Review). The dining room was designated 30/08/07 as a smoking area for one person living in the home. Other people who accessed the service and staff had to breath in the smoke and consume their meals in a smoke filled atmosphere. The registered person is required to take the appropriate measures, to ensure the health and safety of people living in the home and staff members, from having to inhale smoke throughout the day. (This is an outstanding requirement, from a previous report. The identified timescale was 21/11/05. This will be identified within the Management Review). Water distribution temperatures accessible to people living in the home were not consistent. The registered person should ensure that the appropriate measures are undertaken to ensure an ambient temperature of 43oC. One bedroom had a single light bulb with no light shade; the lighting within this room was poor. The registered person should ensure that appropriate actions are taken to ensure that sufficient lighting is provided. Two people living in the home suffered with diabetes. It was difficult to collate information to establish the management of this illness. The registered person is required to address this, to ensure that 8. YA42 13(4)(a) 30/08/07 9. YA24 23(2)(p) 25/08/07 10. YA6 12 and 13(1)(b) 20/08/07 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 30 the identified people are receiving appropriate support and treatment. (Issues relating to the management of diabetes was identified in the previous report of which was an immediate requirement 01/11/06). This area of concern will be identified within the Management Review). The practice of assisting a female to access of male’s bedroom to use his en suite facilities demonstrated a lack of respect of the individual’s rights, privacy and dignity. 11. YA16 12(4)(a) 18/08/07 12. YA35 The registered person is required to address these poor practices to preserve the rights of people accessing the service. 30/09/07 18(1)(c)(i) One person living in the home main mode of communication was Makaton. Staff had not received training in this area. A previous requirement was identified that all staff must undertake communication training relevant to meeting people needs. The timescale stemmed from January 2004 to date. This will form part of the Management review. 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 YA17 Good Practice Recommendations To consider strategies for promoting residents’ dignity during meals and mealtimes, for example tablecloths, DS0000020850.V346343.R01.S.doc Version 5.2 Page 31 34 Walsall Street 2. YA42 3. 4. 5. YA8 YA16 YA42 condiments. The cleaning regime of the identified bedroom, should be reviewed to ensure that the person occupying this room, is provided with the appropriate level of support, to maintain the hygiene standard, to prevent any further presence of mice. People living in the home should be involved in the recruitment and selection of staff. Peoples preferred form of address should be identified within their care plan. An audit of all wardrobes should be undertaken to ensure that are secured to the wall. 34 Walsall Street DS0000020850.V346343.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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. 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