Inspection on 10/05/05 for 45 Hall Green Road

This inspection was carried out on 10th May 2005.

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

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

Other inspections for this house

45 Hall Green Road 10/10/07

45 Hall Green Road 02/05/06

45 Hall Green Road 16/09/05

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 45 Hall Green Road West Bromwich West Midlands B71 3JS Lead Inspector Deborah Sharman Unannounced 10 May 2005 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 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 Stationary 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. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 45 Hall Green Road Address 45 Hall Green Road Telephone number Fax number Email 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 588 4560 Milbury Ms Debie Stagg Care Home 7 Category(ies) of Learning Disability (7) registration, with number of places 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Brief Description of the Service: 45 Hall Green Road is a Residential Care Home providing care and accomodation for 7 adults with a learning disability in a detached seven bedroom house. The service was newly registered and opened in December 2004. The house is on a main road close to Wednesbury town centre and about 5 miles from West Bromwich in the West Midlands. The house is close to local amenities including a mini supermarket, takeaways, hairdresser, green grocer etc. A bus stop is within a minutes walk enabling access to the wider local community. Each bedroom has ensuite facilities furnished with either a bath or a shower. In addition there is a lounge, a designated activity room and separate sensory room where residents can relax, a dining room that seats 12 people and a large private grassed rear garden. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Hall Green is a newly registered service. This was its first inspection and it was unannounced. The Inspection began at 9.00am and finished at 5.15 pm. The Inspector observed the administration of medication, interviewed the manager and spoke privately with a service user who had recently moved in. The Inspector also had the opportunity to speak in detail to the parents of a Service User who had come to collect her for a visit home. The Inspector also spoke to a senior member of staff. The Inspector examined a range of documentation relating to the maintenance of care, health and safety, and recruitment practice. The Inspector also fully toured the environment meeting all meeting all service users. The period prior to this inspection since opening has been a settling in period for all – service users, staff, the manager and the building are all new. The manager, staff, relatives and a service user spoke positively of the settling in period. However it is disappointing that at such an early stage the home has accrued so many requirements to bring about improvement in areas that affect outcomes for service users. What the service does well: What has improved since the last inspection? 45 Hall Green Road is newly registered with the Commission for Social Care Inspection and opened in December 2004. This inspection is the first 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 6 inspection since the service opened and so it is not possible to state what has improved since the last inspection but it was pleasing to see that newly placed service users are being supported to maintain contact with family and friends and to access the community. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, The home’s admissions processes do not sufficiently demonstrate that sufficient care is taken to ensure that residents’ needs are assessed and that their needs can be met or that prospective Service users have the information they need to make an informed choice about where they live. EVIDENCE: A Service User spoken to and case tracked had not had the opportunity to visit the home prior to admission. The manager had met the social worker in the morning and the Service User moved in during the afternoon of the same day. The admission was described as an emergency admission but it was not clear why this was the case. The Service User spoken to said she had not been appraised of the rules of the home and was not provided with a Service User guide, which is waiting to be updated. The Inspector expressed concerns about whether the home is appropriately registered to meet the needs of this Service User from information gleaned from social work history notes provided to the home. There was no Community Care Assessment, no assessment completed by the home and the manager had not been involved in assessing this Service User pre admission. The manager had also not been involved in assessing two other Service users prior to admission. A letter has not been sent to any of the seven new Service Users to confirm that their needs can be met. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 9 The home is now fully occupied. One Community Care Assessment out of seven had been obtained. There were no assessments of any kind for 5 Service Users. There was an in house pre admission assessment for two out of seven residents. A Statement of Purpose was not available within the home for assessment. Reviews have been held for most Service users the Inspector was informed although minutes were not available. The inspector was informed that a long transition process had been undertaken with one service user with staff spending time with him at home for many weeks prior to his move. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 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 standard(s) 6, 7, 9. Care planning and risk assessment systems are not in place to adequately provide staff with the information they need to keep Service Users safe nor to satisfactorily meet Service User needs. The home is beginning to build a culture of enabling Service Users to make choices in their day to day lives which will offer contentment and the opportunity for developing self esteem. EVIDENCE: Assessment of shift records kept daily indicates that choices made by the Service User whom the Inspector case tracked are respected and acted upon. Daily records seen were detailed and provided good evidence of this. A Service User is recorded as having made her own supper. Another entry shows that the Service User asked to go to Birmingham and was supported to go the same day as the request. Care planning and monitoring records must demonstrate how the choices of Service Users including those who are none vocal are understood and acted upon. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 11 Care planning is insufficient. There are no care plans in place for 5 Service Users and two are in their early stages and do not yet include plans to meet significant areas of assessed need. For example the one Service User who has a detailed Community Care Assessment has care plans in place for helping in the kitchen, personal care, tidying the bedroom, and walking in the community. The Community Care Assessment outlines the following as some significant areas of need for this Service User: continence management, oral hygiene, contact with family, behaviour management and epilepsy. These are not included within the plan of care. The lack of behaviour support care planning is of concern given that accident records indicate an occasion where this resident was ‘supported’ in a shop with behaviours that resulted in red marks to the wrist. It is not acceptable to hold joints during any form of physical intervention and appropriate protocols are required to guide staff and to keep Service Users safe. Risk assessments were seen for moving and handling Service Users who are fully mobile. Areas of risk identified by placing social workers (absconding, self injury, placing objects in ears and nose) or in notes provided by previous services have not been controlled through the homes risk assessment process. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 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 standard(s) 12, 13, 15, 16. There is evidence that Service Users are increasingly supported to access the community and friends and family. Performance will be better supported through the development of plans and monitoring systems to meet the assessed needs and preferences of individual Service Users. EVIDENCE: None of the Service Users are engaged in employment, work experience or attend day centres or other day opportunities away from the home. The home is commissioned to provide day activity. The home is central to local amenities and has a mini bus to facilitate access easily. The Inspector observed service users coming and going throughout the day supported by staff. Some service users went to a local supermarket, others went for a walk. The service is new and the manager along with some service users are new to the geographic area and the manager was unfamiliar with some facilities available locally e.g. cinema. The manager must ensure that information and advice are available about local activities, support and resources. One service user spoken to said that although she had not wanted to vote in last week’s general election she had not been offered the opportunity to. The service user 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 13 also said that there was not a planned programme of activity and she was not aware of what she would be doing the following day. The Inspector saw a programme of activity planned for three weeks earlier but a clear system of activity planning has not yet been established. The manager said that the programme was flexible and residents make their choices daily. Given that the home is responsible for providing daytime stimulation, activity plans must be developed, implemented and monitored allowing some flexibility based upon the assessed and recorded interests and wishes of individual residents. Relatives informed the Inspector that their daughter’s initial reluctance to join in activities was respected and that she is ‘treated like an adult’ A resident spoken to said that she is able to and has received phone calls from friends and family and shift notes evidence that she has also received visitors. The parents of a further Service User visited on the day of inspection and informed the Inspector that they drop in unannounced and are always made welcome. The Service User was going home with her parents for an overnight stay. The parents confirmed that they are able to phone and that they also receive phone calls from their daughter. The parents spoken to said that activity levels appear to be increasing. They were aware of visits to Walsall art gallery, shops, a disco and several visits to the supermarket. Contact with family and friends are not included in plans of care, as they have not yet been established. Contact must be included in care plans in accordance with the wishes of Service Users and their family and a system set up to monitor this. One Service User has expressed the wish to receive visits from her boyfriend. The manager is aware of the need to undertake in advance detailed risk assessments and written protocols to be agreed with the Service User. A service user spoken to confirmed that staff always knock before entering her room, that she bathes independently and her privacy is respected, that staff do not open her mail, and that staff address her in the way that she prefers. Visiting relatives also confirmed that staff knock prior to entering. She confirmed she has unrestricted access within the home and concurred with evidence within records that indicate choice over rising and retiring times. Some care plan goals are in place for one resident and these include housekeeping tasks / tidying bedroom. During the inspection Service Users were observed going out in small groups with staff. Residents are all white British. The racial composition of the staff group reflects that of the local community. The manager reported that she has received some complaints from neighbours about noise in the garden. These complaints have not been recorded and must be, including date of complaint, date and nature of investigation, response and outcome. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 14 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 standard(s) 18, 19, 20. Systems to support the heath needs of Service Users are at this time not sufficiently developed. Health screening has not been provided. Lack of assessment and care planning leaves staff without sufficient information to support the health needs of Service Users. The systems for the administration of medication require improvement and potentially place service users at risk. EVIDENCE: Judgements are drawn from a cross section of assessments of need, plans to meet identified need and monitoring systems to demonstrate that plans are being implemented and needs met. These systems are not in place. One resident spoken to said that she manages her personal hygiene independently and that her privacy is respected. It was not possible to verify the level of support she requires as neither assessment nor care plans were available. Daily shift records did note occasions when she took a bath. She verbally confirmed that she chooses what to wear, what to buy and when to rise and retire and shift notes support this. A key worker system is in place and the Service User was able to tell the Inspector who her key worker is. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 15 One of the care plans that is in place is for personal care. This contains a high level of detail, which is not being monitored and evidenced. The manager must ensure that care plans are specific, measurable and monitored. This is a new service and the last service user to be admitted has been resident at the home for 3 weeks. Some Service Users have however been resident since the service opened 5 months ago. No service users have in this time received any health screening and in the absence of care plans health needs are not assessed or planned for. These omissions must be met as a priority and health screening - dentist, optician, hearing, chiropody, medication reviews, breast screening, testicular screening, sexual health in addition to any individual specialist requirements must be evidenced by the next inspection. Disability equipment is not provided within the home. All residents are mobile with the exception of one resident who uses a wheelchair whilst out in the community. The Inspector observed him going out in a wheelchair supported by staff. Lack of written assessment makes it difficult to judge whether aids are required. The Inspector was informed that one Service User uses incontinence pads 24 hours per day and that he is not on a continence programme. Notes from his school held on file show that prior to his admission, although he uses pads, he was following an hourly continence programme that Hall Green must re establish without delay. There are a number of areas for improvement in respect of medication practice and several requirements have been made. Concerns include training (provided the Inspector was informed by the provider but not accredited or evidenced), the administration of rectal diazepam, lack of guidance in respect of medication prescribed as ‘as required’, lack of a system to identify errors, a missing tablet and unsafe administration practice observed by the Inspector. Consent to medication administration is not on service users files and neither is a record of current medication. There are no controlled drugs. The home is not receiving support visits from a contracted pharmacist. Medication is stored appropriately. The medication policy is very comprehensive but does not include guidance that in the event of death all medicines must be retained for seven days. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 16 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 standard(s) 22,23 The home is not able to evidence that it has satisfactorily responded to complaints. Records of an incident where a Service User used challenging behaviour in the community does not evidence that staff are sufficiently trained to respond in a manner that will support and protect the Service User. EVIDENCE: These Standards were not fully assessed. It was not planned to assess these Standards at this inspection. It is noted however that the home has received complaints from the neighbour. These complaints have not been recorded as is required. The manager is required to record all complaints including retrospective complaints. The complaints log must include the details of the complainant, details of the nature of the complaint, the date of the complaint, steps taken to investigate the complaint, the outcome of the complaint i.e. upheld, not upheld, partly upheld, not resolved, a copy of any letter sent to the complainant and the date of response to the complainant. The manager verbally demonstrated knowledge of the reasons for behaviour that challenges and a commitment to identifying and resolving triggers to behaviour and diffusing situations to avoid escalation. The manager explained at the beginning of the inspection that restraints / physical interventions are not required with the current Service User group. The accident book showed that a physical intervention was employed in March when a current Service User exhibited behaviours in a local shop. The accident book indicated that pressure had been applied to wrists (red marks), which is not acceptable practice, and not in line with Department of Health Guidelines. An events sheet had been completed but is not sufficient in detail, as it did not 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 17 include the nature of the physical intervention – only that the Service User had been ‘supported’. Notification of all physical interventions must be made to the Commission for Social Care Inspection. Notification in respect of this incident was not received. The manager said that all staff have received appropriate training in non aversive crisis intervention provided by a staff member accredited to train in such techniques, but evidence of training was not available. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29, 30. The standard of the environment within this home is good, providing service users with an attractive, spacious and homely place to live. Improvement in some aspects of infection control will reduce risk to staff and service users. The home is not able to demonstrate that the environment meets the assessed needs of Service Users. EVIDENCE: Hall Green Road is homely and comfortable with no mal odour. Room and communal spaces dimensions were not available on site but from observation it appears that available space exceeds the national minimum standard. The home is fully occupied with permanent Service Users and the manager said that the intention is not to provide respite or short-term care but the Statement of purpose was not available to clarify this. There was no evidence that the local fire service or Environmental Health Department had visited. The manager was unsure whether the Food Safety Unit of the Environmental Health Department was aware of the new service and she is required to check this. There is not a written planned maintenance and renewal programme for the fabric and decoration of the premises and some rooms are now in need of 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 19 redecoration (lounge/ stairs) and repair. The activity room wall has sustained damage to the plaster. All residents have a single room. All have ensuites. Five bedrooms have baths in the ensuite and 2 have showers. Bedrooms are well furnished with most of the facilities required by national standard. Omissions are two comfortable chairs for which there is space (one has been provided). Two bedrooms have 2 chairs, which have been supplemented by family. The other shortfall is that windows are placed high and do not provide a view when seated as per Standard 26.2 vii. All other facilities are provided. Rooms are in the process of being personalised. Locks are appropriate. Two service users have keys. One service user confirmed this. Care plans must record reasons for withholding keys. As all bedrooms are fully ensuite there are no communal bathrooms. The draw back of this is that service users do not have a choice of bath or shower as ensuites are fitted with one or the other. The lack of assessments and care plans do not account for service user preference in respect of bathing and so a judgement cannot be made as to whether the bathroom and toilet facilities provided meet their assessed needs. There are two communal toilets downstairs and two upstairs in addition to the ensuite toilets. There are no adaptations. Bathroom and toilet locks are thumb turn operated internally but can be overridden from the outside in an emergency. Ensuites are finished to a very high standard. There is a range of shared space – lounge, dining room, activity room, sensory room and a large safe garden. Communal space available on average to each Service User was not known on inspection day. Staff do not sleep in therefore sleep in facilities are not available but lockers have been provided for staff. The premises are no smoking. Premises are clean and free of odour. Laundry facilities are appropriately sited but are small. This compromises good infection control practice, as it is difficult to separate soiled and clean linen. Clean linen had not however been left within the laundry. The space within the laundry at Hall Green is further compromised as the industrial washer and dryer have been installed so that they sit within the centre of the laundry rather than against the wall. This has left pipes and wires exposed to the rear and made it impossible to safely retrieve items that have fallen behind the machines. Hand washing facilities are available within the laundry but have not been identified as such and items were found soaking in the hand washbasin, which is inappropriate. A sign to remind staff to wash their hands was not available and neither were laundry procedures, infection control or COSHH guidelines. The ironing board is stored in the laundry and in the interest of avoiding cross infection should be stored elsewhere. The home has a clinical waste contract. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 20 The kitchen was clean. Temperature records of the fridge and freezer must improve as temperatures are being taken once per day when guidance within the home states twice per day. Acceptable temperature ranges are also stipulated in writing and staff are asked to report non temperature compliance to a senior. Only one staff is recorded as doing this. Temperatures are consistently recorded as not compliant particularly the freezer where, throughout the month of April temperatures of –14, -15, -16 and –17 are consistently recorded with no action taken. Hot food temperatures are not being taken as the probe is reported to have broken and not replaced. The probe had not been calibrated and this is further required. Fresh food that had been frozen had not been dated on the day frozen indicating that the use by date has expired which is an offence. Meat was stored in the middle of the freezer and must be at the bottom. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 All recruitment checks as required by regulation are not being obtained potentially leaving service users at some risk. EVIDENCE: As this is a newly developed service many new staff have been recruited, some of whom are new to the care profession. There are many positive features of the staff recruitment process with many areas of compliance. There were some shortfalls which must be addressed. Three staff files were assessed. It was pleasing to see 3 application forms, 3 Criminal Record Bureau checks and POVA first checks obtained prior to commencement in post, 3 medical declarations (although one had not been fully completed), 2 contracts of employment. Shortfalls in recruitment documentation are as follows: Insufficient identification, no photographs of staff members on file, the General Social Care Council’s Code of Conduct has not been issued to staff, no job description, no contract for one employee. There was some evidence of interview but this should be developed. It is pleasing that the application form asks applicants to account for any gaps in their working history. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 22 There are no volunteers engaged at Hall Green but the volunteer policy states that recruitment checks are required (CRB and 2 references). The policy also appropriately states that volunteers must be supernumerary and must not be involved in personal care. The recruitment policy was not available. A note in the file said it is currently being updated and is at final drafting. Agency staffs are used. There is no written confirmation that appropriate recruitment checks have been carried out for those staff engaged from the agency. The home must hold written confirmation that individually named agency staff have had listed appropriate checks satisfactorily conducted. The manager said that it is planned to involve service users in future staff selection. The probationary period for new staff is 6 months. One member of staff was terminated within the probationary period. This should have been notified to the Commission for Social Care Inspection as a regulation 37 notice. Induction training to the required standard has not been provided and timescales for its provision have not been met. The home is carrying 8 fulltime staff vacancies, four of which have been recruited to and the appropriate checks are being awaited prior to commencing. Existing staff, agency staff and the manager are covering care hours. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 The manager has appropriate experience, which must now be supplemented by achieving the required qualifications to support the process of managing a care home effectively. Subsequent inspections will provide better evidence as to how effectively the manager is supporting the development of the home and welfare of service users. EVIDENCE: The Commission for Social Care Inspection has registered the manager as manager of Hall Green Road. Certificates were seen to evidence her qualifications in NVQ 2 and 3 and City and Guilds in Advanced Management in Care. The manager is aware that she now requires the Registered Managers Award including NVQ 4. The manager has occupied a management role in other learning disability services since 2001 and has, she informed the Inspector, been employed by this provider since 1995. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 24 Maintenance records were assessed. Most were available and in date. Exceptions to this were a water bacteriological test certificate, a water chlorination certificate, portable appliance test records, (not all appliances are new as some have been brought to the home by service users). Water temperature records showed temperatures to be compliant for the week of the inspection but prior to this, recommended ranges had been exceeded up to 45 and 47 degrees on repeated occasions with no action having been taken. Part of the fire alarm system was faulty on the day of inspection and had been for a fortnight. The Inspector asked the manager to put a sign next to the faulty break glass (siren not activated from zone 3). The contractor was phoned during the inspection and undertook to visit the following day. Therefore an immediate requirement was not issued. Fire drills had been carried out in January and May 2005 with all staff names recorded. All inhouse fire system checks were in order. Non compliant kitchen and food temperatures have been referred to under standard 30. 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 1 2 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 2 3 3 2 Standard No 11 12 13 14 15 16 17 x 1 2 2 2 3 x Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 45 Hall Green Road Score 2 1 1 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 26 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 YA1 Regulation 4 Requirement The Registered Manager must ensure that the Statement of Purpose is updated, available and includes the physical environmet Standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4, 28.2 The Service User Guide must be updated and must be distributed to all Service Users. Copies of Community Care Assessments must be obtained for all Service Users. (Community Care Assessments must be obtained pre admission) Copies of all assessments undertaken pre admission must be obtained and held on file. The Registered Manager must ensure that an individual Service User plan (based upon the Care Management Assessment Care Plan or the homes own needs assessment) is developed that addresses all of the Service Users identified needs including personal, social, behaviour support, communication, E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Timescale for action 30.06.05 2. 3. 1 2 5 14 30.06.05 31.5.05 and pre admission for all new admissions to the home 31.05.05 30.06.05 4. 5. 2 14 2,6,7,13,14 15 , 15,16,17, 18, 19,20 45 Hall Green Road Version 1.30 Page 27 6. 3 14 7. 3 14 8. 3,4 14 9. 4 12(2)(3) 10. 6 14, 15 11. 9 13(4) 12. 9 13(4) 13. 9 13(4) nutrition, healthcare,financial management, decision making, restrictions, contact with family, wishes in respect of voting, mail management, preferred routines, keyholding, preferred form of address, medication. The Registered manager must ensure that all admissions comply with the homes category of Registration. The Registered Manager must write to all Service to confirm where appropriate that the home can meet the Service Users assessed needs. The manager must review the primary care needs of DF confirming the outcome and any plan of action to the Commission for Social Care Inspection by Friday 13 May 2005. Trial visits must be offered to all new Service Users considering admission. Trial visits must be recorded. Reasons for not providing trial visits must be documented. The Registered Manager must ensure that systems are established to monitor and evidence the meeting of needs identified in the plan of care. Risk must be assessed prior to admission to the home and measures put in place prior to admission to minimise identified risk. Risk assessments must be carried out for all service users for all areas of risk identified preadmission e.g. absconding, self injury, placing objects in ears and nose. Risk assessments must also be carried out for all Service Users in respect of the following; drowning, nutrition, access to 13 May and at next admission 31.05.05 13.05.05 Next Admission. 30.06.05 Next Admission 20.05.05 20.05.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 28 the community, road safety 14. 13 12(3) Service Users wishes in respect of voting must be sought and must be recorded in the plan of care. This must be kept under review. Service users must be enabled to vote if they wish. This must be evidenced. Written activity plans for each individual Service User must be developed and implemented based upon assessment of need. Outcomes must be monitored and evidenced The manager must ensure that information and advice are available about local activities, support and resources. The Registered Manager must ensure that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. The Registered Manager must ensure that all Service Users are offered minimum annual health checks for vision, hearing, medication. The manager must ensure that should a Service User decline to attend screening offered that this is recorded. The practice of signing administration records prior to administration of medication must cease with immediate effect. Action taken must be confirmed in writing to the Commission for Social Care Inspection by Friday 13th May 2005.Medication must be administered safely and as per the homes policy. The practice of stacking tots that contain medication for several individuals must stop with immediate effect. Action taken 30.06.05 15. 16. 13 14 12(3) 15 Next Election 30.06.05 17. 13 16(2)(m)( n) 12, 13 30.06.05 18. 19 30.05.05 19. 19 12, 13 31.12.05 20. 20 13(2) 10.05.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 29 21. 22. 20 20 13(2) 13(2) 23. 20 13(2) 24. 20 13(2) 25. 26. 20 20 13(2) 13(2) 18(1) (c 27. 28. 20 20 13(2) 13(2) must be confirmed in writing to the Commission for Social Care Inspection by Friday 13th May 2005. Prescriptions must be photocopied The Registered Manager must ensure that staff report without delay any error or gap in administration records to ensure effective steps can be taken to ensure the welfare of Service Users. The manager must implement a recorded system of auditing medication records. The Registered Manager must investigate with written outcomes the gap in medication records for OB 9pm 30.4.05 and provide the outcome of investigation in writing to the Commission for Social Care Inspection. The Registered Manager must ensure that there is written criteria for the administration of all medication prescribed as as required. This must be based upon medical advice from the prescriber. The Manager must ensure that the use of rectal diazapam for 2 residents is medically reviewed. Medication training must be reviewed to ensure that accredited training is provided. Evidence of training provided must be held upon the premises. The Registered Manager must obtain quarterly pharmacy support visits for the home. The Medication Policy must include guidance that following the death of a service user all medicines must be kept for 7 days 31.05.05 10.05.05 31.05.05 31.5.05 31.5.05 30.6.05 31.5.05 30.6.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 30 29. 20 13(2) 30. 20 13(2) 37 31. 22 22 32. 23 13(8) 13(6) 15 37 17(1)(a) Schedule 3(3)(p) The manager must ensure that all staff kniow what action to take in the event of medication being dropped. The manager must investigate with a written outcome provided to the Commision for Social care Inspection the missing dropped lamotrigine tablet not recorded as returned to the pharnmacist. All complaints including those already received by the home must be recorded including date received, complainant, details of complaint, outcome of investigation, date complainant responded to and whether the complaint is upheld not upheld, part upheld, unresolved etc. A detailed behaviour support plan including approved physical intervention techniques with guidance as to criteria for use must be in place for Service User O and all other service users whose behaviour requires support by Friday 13 May 2005 with copies submitted to the Commission for Social Care Inspection by this date. All physical interventions / restraints must be notified in writing to the Commission for Social Care Inspection without delay. The nature of the restraint must be recorded. Certificates to evidence training in the management of challenging behaviour and physical intervention must be available on the premises. The provider must confirm in writing to the Commission for Social Care Inspection that physical intervention training provided complies with Department of Health and the 10.5.05 30.6.05 31.5.05 for existing complaints and without delay for any new complaints. 13.5.05 33. 13, 23 18(1)(c 30.6.05 34. 23 13(6) 30.6.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 31 35. 36. 24 24 23, 13(4) 16(2)(c 37. 38. 24 24 23(2)(b) 23(2)(d) 23 British Institute of Learning Disability Guidelines. Wardrobes must be secured to the wall to prevent toppling Two comfortable chairs must be provided in each Service Users bedroom or reasons for not doing so must be recorded on individual care plans The lounge must be decorated There must be a written planned maintenance and renewal programme for the fabric and decoration of the premises available within the home. Damaged plaster work to the wall of the activity room must be made good. Infection control procedures in the laundry must improve based upon advice of the Infection control nurse which must be sought. The manager must ensure that the Food Safety unit of Environmental Health Department is aware that Hall Green is a new service. Temperatures of fridges and freezers must be taken and recorded twice per day. The manager must ensure that temperatures are compliant and therefore safe. Action must be taken without delay where temperatures are not compliant and action taken must be recorded. Hot food temperatures must be taken prior to serving, ensuring that temperatures meet the safe range. Temperatures must be recorded. Temperature guages must be regularly calibrated to ensure accuracy with calibration recorded. 30.5.05 31.8.05 30.9.05 30.6.05 39. 40. 24 30 23(2)(b) 16(2)(j) 13(3) 30.6.05 30.6.05 41. 30 16(2)(j) 13(3) 31.5.05 42. 30 13(3) 16(2)(j) 10.5.05 43. 30 13(3) 16(2)(j) 31.5.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 32 44. 33 18 45. 30 13(3) 16 (2)(j) 46. 47. 35 34 18 19 48. 49. 34 34 Appendix 2 18(1)(4) 50. 35 18 The manager must calculate care staffing hours requirements using a recognised tool based upon the dependencies of Service Users. This must be provided to the Commission for Social Care Inspection and kept under review. The outcome must be compared to care staffing hours provided with an action plan provided (copy to CSCI) to meet any discrepency between the two figures. Refridgerated and frozen meat must be stored in the bottom of the fridge and bottom of the freezer. Food that is bought fresh and frozen must be dated with the date it has been placed in the freezer. All training certificates must be available to evidence all training provided. The manager must ensure that all recruitment documentation in accordance with Schedule 2 is obtained for all existing staff and prior to the employment of any new staff. This must include written confirmation of specified checks for all individually named agency staff used by the home An up to date recruitment policy must be available within the home. Each staff member must be provided with a copy of the General Social care Councils Code of Practice and must sign to evidence receipt. Signature must be held on staff members individual personnel file. LDAFF induction and foundation training must be provided to new unqualified social care staff. This training must be provided within approved timescales eg 6 weeks and 6 months. 30.6.05 10.5.05 30.6.05 30.6.05 for existing staff. Prior to next new starter. 31.5.05 30.6.05 30.6.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 33 51. 37 9 52. 40 17(1)(a) 53. 41 37 54. 42 23(4) 55. 42 13(4) 56. 42 23(4) The Registered Manager must submit an action plan to the Commission for Social care Inspection to indicate how and with what timescales she will achieve NVQ 4 in care and the Registered Managers Award. Night records must contain greater detail to evidence the regularity and nature of night checks which must be determined by risk assessment and recorded in plans of care All notifiable incidents as defined by Regulation 37 must be notified without delay to the Commission for Social Care Inspection. The Registered Manager must seek advice from the West Midlands Fire Service in relation to the sufficiency of the fire risk assessment in place. The manager must ensure that a written risk assessment in relation to the general security of the premises is undertaken with control measures identified and implemented to reduce any identified risks. The manager must (as agreed) provide written confirmation to the Commission for Social Care Inspection that the fault with the fire alarm system has been satisfactorily addressed. The manager must ensure that water temperatures from all outlets comply with the recommended safe temperature range and that systems are in place to remedy none compliant temperatures and to keep service users safe. The provider must review the premises against the National Minimum Standard which states 30.6.05 30.5.05 Next Incident 31.5.05 30.6.05 13.5.05 57. 42 13(4) 10.5.05 58. 26 23(2)(a) 30.6.05 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 34 59. 24, 30 23 that service users bedrooms include a window which opens at a level providing a view when seated and to respond in writing to the Commission for Social Care Inspection The provider must review the layout of the washing machines in the laundry to effect an unobtrusive use of space, safety and effective cleaning. 30.6.05 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 Good Practice Recommendations 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 35 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen B628DAAddress 4 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 45 Hall Green Road E55 S62453 Hall Green Road 100505 V229768 Stg 4.doc Version 1.30 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!