Inspection on 16/09/05 for 45 Hall Green Road

This inspection was carried out on 16th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 64 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 10/05/05

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 45 Hall Green Road West Bromwich West Midlands B71 3JS Lead Inspector Deborah Sharman Unannounced Inspection 16th September 2005 09:00 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 45 Hall Green Road Address 45 Hall Green Road West Bromwich West Midlands B71 3JS 0121 588 4560 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) Milbury Care Services Ltd Miss Debie Ann Stagg Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005. 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 DS0000062453.V258434.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken by one Inspector, meaning that the home had prior notification of the inspection date and was able to prepare. The Inspection began at 9.30a.m and concluded at 5.30pm. The manager of the home supported the inspection process throughout the day. The Inspector was able to assess documentation, case track the care service users receive from the point of admission to the home, fully assess some core standards and progress made towards previous requirements issued to ensure improvements. The Inspector was also able to talk in detail to a staff member and observe lunchtime. What the service does well: What has improved since the last inspection? Twelve areas identified previously as requiring improvement have been assessed as fully met at this inspection. Improvements include updating the Service User Guide to ensure that accurate information about the homes services is provided, the implementation of a behaviour support plan for a named service user to better guide staff and protect the service user. Wardrobes are now all secured to walls and hot food temperatures are monitored promoting service user safety. Cold meats are now stored more safely too. Night records have improved which is ensuring the regularity and nature of checks made on service users throughout the night. A fault with the fire alarm has been rectified and the Commission for Social care Inspection is now receiving notification of any incident that affects the welfare of service users. Guidance in respect of recruitment procedures is now available within the home. Care planning had also improved for most service users with many omissions now included. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 6 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 DS0000062453.V258434.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 There was no evidence to show that service users and /or their representatives have been made aware of the terms and conditions of residency. EVIDENCE: Hall Green Road is a newly registered service, this being only the second inspection since it opened. Therefore all service users have been newly admitted with one service user being admitted to the home since the last inspection. There were no contracts available for any of the service users. The manager was not aware of any contracts being issued to service users or being signed. The Registered manager did not assess the suitability of the new service user for the home this was undertaken by a staff member from head office. A Community Care Assessment undertaken by the placing Social Worker was however available but had not been followed. Contrary to previous requirement there was no evidence on the service users file that this pre admission assessment had been undertaken. Furthermore the Inspector queries the wisdom of the registered manager admitting to the home service users she has had no role in assessing. There was no evidence that service users had been written to in order to confirm that their needs could be met by the home. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 A care plan was not in place to sufficiently guide staff to provide appropriate care for a newly admitted service user and identified risks were not appropriately managed to protect this service user. EVIDENCE: These Standards were not fully assessed at this inspection but some concerns were identified that required immediate action. Care plans had improved for some service users and provide detailed guidance based upon service users abilities and praise. However a new service user admitted to Hall Green Road in July 2005 did not have a plan of care or any risk assessments in place to meet areas of identified need and risk e.g. supervision in the community, eating compulsion etc. The placing social worker identified the risk of this service user running across a road to obtain food or snatching food from a child in the street. His Community Care Assessment states he must have a staffing level of 2:1 in the community until a risk assessment determines otherwise. There is not a risk assessment in place that determines the level of risk and staffing is being provided at 1:1 in the community not 2:1. The Inspector observed the service 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 10 user’s tendency to lunge and snatch food from a fellow service user at mealtime within the home. This is the service user who absconded (see Standard 23) and was unsupervised on the roads at this time placing him at risk. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Some service users have been provided with a holiday as part of the contract price. Systems are not in place to promote the meeting of nutritional need, cultural dietary needs and preferences EVIDENCE: A holiday was planned for 2 service users for the 19th September to Burnham on Sea, self-catering. Two staff were to accompany them. The manager said that although holiday risk assessments had not been completed this was being currently worked on. The provider contributes £200.00 per service user to the cost of the holiday and this had covered the entire cost. Staff are provided with out of pocket expenses by the provider. Holidays for other service users had not been booked but were being planned. The Inspector was able to see lunch being served and eaten. It was omelette as per the menu and it looked and smelled very appetising. A service user lunged to grab another service users food and the manager appropriately directed staffs response. As there is no care plan in place for this service user guidance re the management and deflection of this behaviour is not available. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 12 The service user would benefit from psychology in put to identify the triggers for this behaviour and diffusion tactics. Service users are encouraged to eat together in the dining room but this is flexible. Pictorial menus are being worked upon and meals are offered four times per day including supper. Service users can help themselves to food items / snacks in between meals if required. Fridges, freezers and storage cupboards were well stocked with food provisions. Care plans are in place stating that service users are actively supported to help prepare meals. One service user does not eat beef for cultural reasons. The menu does not plan an alternative for this service user but other records show that on occasions an alternative is provided. However no alternative was evidenced when beef was served on 10th August. Discussion with staff showed that they require further support to understand this service users cultural dietary needs. The care plan states no beef but a staff member understands that this is only at certain times on the calendar but did not know when and said she would rely on the service users family to inform her. This service users family provide some culturally appropriate food. Another service user is recorded as not liking curry. There was no evidence that this had been accommodated and that she had been provided with an alternative. Upon questioning the Inspector was told that the service user does now like curry but that the care plan had not been amended. Systems are not in place to support service users nutritional health. For example service users weights are not being taken and recorded although the manager is aware of the need for this. Nutritional assessments are not in place and nutritional care plans are also not in place. There appears to be a general belief that some service users need to lose weight, without any systems in place to determine this or to set a goal and a method to achieve it. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 EVIDENCE: These Standards were not assessed at this inspection. The new service user case tracked had in the two months since his admission had had a chiropody appointment but no other health screening appointments. A previous requirement is in place to ensure that all service users receive all health screening appointments regularly. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are generally protected but an improvement in some areas would offer greater protection. EVIDENCE: The home has a corporate adult protection policy, which is largely very comprehensive and detailed. Its general high standard however is compromised by a potentially misleading flow chart designed to be a quick reference guide. This flow chart wrongly states that a victim’s permission must be obtained before referring any allegation of abuse to Social Services and this contradicts the policy and the spirit of multi disciplinary local adult protection guidelines (a copy of which was not on the premises). There have been no restraints but since the last inspection a service user absconded. Procedures to ensure his safe return were followed and he was returned safely on this occasion to he home. Systems have been reviewed to ensure that the risk of this happening again is minimised. The home has not provided Adult Protection training for most staff. Three staff have done it and 2 were booked to attend on 14.10.05 leaving 15 staff who require this training. A staff member spoken to demonstrated a good understanding of what abuse is and her responsibility to report any concerns. The home’s policies and practices regarding service users money are good and protect service users interests in general. The financial records of two service users were inspected and there were no concerns. The only area identified for improvement is the need to ensure that two staff members sign to authorise expenditure as per the home’s policy. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed at this inspection. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 The ratios of care staff to service users is not sufficiently maintained at all times to ensure that service users needs are met compromising their safety and care. All staff have not completed all mandatory training but a training programme is in place. Staff have not to date received supervision but there are plans to address this. EVIDENCE: A placing social worker identified the risk of a new service user running across a road to obtain food or snatching food from a child in the street. His Community Care Assessment states he must have a staffing level of 2:1 in the community until a risk assessment determines otherwise. There is not a risk assessment in place that determines the level of risk and staffing is being provided at 1:1 in the community not 2:1. The Inspector was informed that all service users require 1:1 support within the home and that the home’s staffing ratio is therefore seven staff on duty as a minimum at all times (with the exception of nights when there are 2 waking night staff). Eight staff would be required on occasions when the service user referred to above is supported to access the community. Assessment of the rota shows that this minimum-staffing ratio has not been maintained particularly after 3pm and when staff phone in sick or are on annual leave. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 17 The rota shows many occasions when after 3pm there were only five and six staff on duty instead of seven with three staff being agency staff compromising the continuity of care provided. Two staff have been recruited but have not yet started as they are awaiting recruitment checks. Contingencies are not currently adequate and urgent action is required. The managers role is not specified on the rota but assessment of it shows that she is receiving inadequate supernumerary time to manage the home but that currently the provision of supernumerary time would further reduce the care staffing ratio. The Deputy manager coordinates the training programme. The home does not have a training budget available as there is a centralised training function. Since the last inspection a training matrix for the staff team has been devised and provides comprehensive training information. Five new staff have not been inducted to the required national standard. They have not started an induction programme within the timescale that it is expected to be completed. The manager stated that training is hindered both by the availability of training but also that it has been difficult to release staff for training as the home has not been fully staffed. No one on the staff group has NVQ qualifications as the staff team is new and many are new to care. However nine staff have begun their NVQ level 2 in care which is positive. The majority of staff still need to do most courses. Infection Control training has not been done by any staff, although two places were booked for October. The majority of staff had not done Fire training and those that had were due again. This provides a significant risk. However the training matrix provides the coordinator with the required information and systems are in place to ensure that there is a programme of training but managers at the home are frustrated by the slow availability of courses. Staff have not been provided with supervisions since the home opened but the manager is starting to address this by delegating supervisory responsibility between the management team. The plan is to start the supervision programme in October. Supervision has however been provided where performance has particularly needed support. Staff spoken to said that they feel well supported. The Deputy manager was looking forward to attending a four-day supervision training course at the end of the month. The manager is also aware of the need to undertake annual appraisals and stated that a pro forma is available, but at the time of inspection the home had not been open a year. A copy of the home’s grievance and disciplinary procedure is available to staff. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42. There are no quality assurance systems in place to support the home’s selfassessment of performance. Health and Safety performance is mixed with some significant omissions that risk service users safety. EVIDENCE: The manager said that the provider visited Hall Green on one day in August and undertook a rigorous ‘inspection’ as a quality assurance pilot scheme. But she has not received feedback and there are no outcomes available within the home. Satisfaction questionnaires are not issued to service users or their representatives or to third parties. There is no development plan for the home on the premises. Notification of the announced inspection was appropriately displayed. Fire training was assessed and is not sufficiently provided. Five staff in total are said to have undertaken fire training in April and May 2005 although there is no certification or other evidence to support this. Four fire training places in 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 19 total have been booked for October and December 2005. On the day of inspection sixteen staff have not done fire training in ten months since the home opened. By December if all 4 booked places are attended 9 staff out of 21 will have been provided with fire training in 12 months. Twelve staff will not have received fire training in 12 months of employment since the home opened. The fire procedure is not sufficient. The home has a corporate one which does not address the specifics of the home and does not guide staff of action to take in the event of fire. A fire risk assessment was available and was detailed but would benefit from being dated. The previous requirement to ensure the Fire Service review the adequacy of the risk assessment has not been met. Fire drills have not been carried out. The first aid box was well stocked. Four staff have done emergency aid training with one being an appointed person. Two more staff are booked onto emergency aid training. Hazardous substances appear to be managed appropriately. Infection control training has not been provided and there is not an infection control risk assessment in place. It was a previous requirement from the last inspection to ensure that cold food storage temperatures comply with the safe range. Inspection has shown this to be consistently not maintained. From 4 September 2005 to 16 September 2005 freezer temperatures ranged daily from minus 12 degrees to minus 17 degrees with no action taken to safeguard the health of service users. The Inspector checked the temperature readings and on the day of inspection the freezer temperature in the kitchen was minus 12 degrees and the freezer in the storeroom measured minus 15 degrees. Freezer temperatures must be maintained at minus 18 and below. Accident records were assessed. In nine months there have been 22 accidents, many related to service users conditions e.g. epilepsy. The manager should counter sign accident records and indicate action to be taken to minimise the risk of a repeat to better manage accidents. As per the previous inspection, induction training is not being provided in a timely way to adequately prepare new staff for role and there was no evidence of this training (LDAFF Induction) other than verbal evidence. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 1 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 1 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 1 x 2 1 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 45 Hall Green Road Score x 1 x x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 2 x DS0000062453.V258434.R02.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 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 Requirement first issued and not met since 10th May 2005. Copies of Community Care Assessments must be obtained for all Service Users. (Community Care Assessments must be obtained pre admission) Requirement first issued and not met for existing service users since 10th May 2005. Community Care Assessment was in place for newly admitted service user. Copies of all assessments undertaken pre admission must be obtained and held on file. Timescale for action 30/11/05 2 YA2 14 30/11/05 3 YA2 14 31/10/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 22 4 YA2 14 New Requirement at September 2005. To review the role of the Registered manager in relation to carrying out preadmission assessments. 30/11/05 5 YA3 14 New Requirement September 2005 The manager must provide in 30/11/05 writing to all service users that the home can meet their assessed needs. New Requirement September 2005. The Registered Manager 31/10/05 must write to all Service to confirm where appropriate that the home can meet the Service Users assessed needs. Requirement first issued and not met since 10th May 2005. Trial visits must be offered to 30/09/05 all new Service Users considering admission. Trial visits must be recorded. Reasons for not providing trial visits must be documented. Requirement first issued and not met since 10th May 2005. Service user contracts must 30/11/05 be available on the premises. New Requirement at September 2005. To write and implement a care plan by Friday 23 September 2005 for S.T based upon assessed needs. Immediate Requirement at 6 YA3 14 7 YA4 12(2)(3) 8 YA5 5 9 YA6 15 23/09/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 23 September 2005. 10 YA6 15 The Registered Manager 30/11/05 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 , social, nutrition, healthcare,financial management, decision making, restrictions, contact with family, wishes in respect of voting, mail management, preferred form of address. Many areas have been addressed and have been deleted those that have not been met or not sufficiently met remain. Requirement first issued and not fully met since 10th May 2005. Risk must be assessed prior to admission to the home and measures put in place prior to admission to minimise identified risk. Requirement first issued and not met since 10th May 2005. Risk assessments must be carried out for all service users for all areas of risk identified preadmission e.g. self injury, placing objects in ears and nose. Requirement first issued and not met since 10th May 2005. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 24 11 YA9 13(4) 30/09/05 12 YA9 13(4) 30/09/05 13 YA9 13(4) Risk assessments must also be carried out for all Service Users in respect of the following; drowning, nutrition, access to the community, road safety Requirement first issued and not met since 10th May 2005. To write and implement risk assessments by Friday 23 September 2005 for ST to minimise all assessed risk. Immediate Requirement at September 2005 31/10/05 14 YA9 13(4) 23/09/05 15 YA13 12(3) Service Users wishes in 31/10/05 respect of voting must be sought and must be recorded in the plan of care. This must be kept under review. Requirement first issued and not met since 10th May 2005. Service users must be enabled to vote if they wish at next election. This must be evidenced. 16 YA13 12(3) 30/09/05 17 YA13 Requirement first made May 2005 and not assessed at September 2005. 16(2)(m)(n) The manager must ensure that information and advice are available about local activities, support and resources. Requirement first issued 10th May 2005. Not assessed at this inspection Written activity plans for each individual Service User must be developed and implemented based upon DS0000062453.V258434.R02.S.doc 31/10/05 18 YA14 15 31/10/05 45 Hall Green Road Version 5.0 Page 25 assessment of need. Outcomes must be monitored and evidenced Requirement first issued 10th May 2005. Not assessed at this inspection The manager must ensure that there is sufficient guidance for staff and that staff understand explicitly service users cultural dietary requirements. 19 YA17 12 31/10/05 20 YA17 Sch 3 / 4 New Requirement at September 2005. Nutritional assessments must 31/10/05 be undertaken for each service user, kept under regular review and must be acted upon where risk is identified. New Requirement at September 2005. 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. Requirement first issued and not met since 10th May 2005. Some progress. Health now in care plan but not specific or measurable. 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 DS0000062453.V258434.R02.S.doc 21 YA19 13 30/09/05 22 YA19 12, 13 31/12/05 45 Hall Green Road Version 5.0 Page 26 offered that this is recorded. Requirement first issued 10th May 2005. Not assessed at this inspection. Service users must be regularly weighed with outcomes recorded and action taken where necessary. New Requirement at September 2005. Prescriptions must be photocopied Requirement first issued 10th May 2005. Not assessed at this inspection. 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. Requirement first issued 10th May 2005. Not assessed at this inspection. 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. Requirement first made and not met since May 2005. The Registered Manager must ensure that there is written criteria for the DS0000062453.V258434.R02.S.doc 23 YA19 12, 13 31/10/05 24 YA20 13(2) 30/09/05 25 YA20 13(2) 30/09/05 26 YA20 13(2) 31/10/05 27 YA20 13(2) 30/09/05 45 Hall Green Road Version 5.0 Page 27 administration of all medication prescribed as as required. This must be based upon medical advice from the prescriber. Requirement first issued 10th May 2005. Not assessed at this inspection. The Manager must ensure that the use of rectal diazapam for 2 residents is medically reviewed. Requirement first made 10th May 2005. At this inspection in process. GP referred to epilepsy nurse team. Medication training must be reviewed to ensure that accredited training is provided. Evidence of training provided must be held upon the premises. Requirement first issued and not met since 10th May 2005. The Registered Manager must obtain quarterly pharmacy support visits for the home. Requirement first issued and not met since 10th May 2005. The Medication Policy must include guidance that following the death of a service user all medicines must be kept for 7 days Requirement first issued and not met since 10th May 2005. Manager has in the meantime ensured this guidance is on medication cabinet. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 28 28 YA20 13(2) 30/09/05 29 YA20 13(2), 18(1)(c) 31/10/05 30 YA20 13(2) 31/10/05 31 YA20 13(2) 31/10/05 32 YA22 22 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. 31/10/05 33 YA23 18(1)(c) Requirement first issued and not met since 10th May 2005. Certificates to evidence 31/10/05 training in the management of challenging behaviour and physical intervention must be available on the premises. Requirement first issued and not met since 10th May 2005. 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 British Institute of Learning Disability Guidelines. Requirement first made and not met since May 2005. The Adult Protection flow chart must be reviewed in relation to the comment re victim’s permission and referral to Social services. New Requirement at September 2005. The Manager must obtain a copy of the host Local Authority Adult Protection 34 YA23 13(6) 30/11/05 35 YA23 13(6) 30/11/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 29 Procedures. New Requirement September 2005. All staff must receive adult 31/12/05 protection training. New Requirement at September 2005. Two staff must sign to authorise and account for financial activity in respect of service users money as per the home’s corporate policy. New Requirement at September 2005. Two comfortable chairs must be provided in each Service Users bedroom or reasons for not doing so must be recorded on individual care plans Requirement first issued and not met since 10th May 2005. The lounge must be decorated 36 YA23 13(6) 37 YA23 13(6) 30/09/05 38 YA24 16(2)(c 31/10/05 39 YA24 23(2)(b) 23(2)(d) 30/11/05 40 YA24 23 Requirement first issued and not FULLY met since 10th May 2005.(Staff have tried to make good by touching paintwork up) There must be a written 30/11/05 planned maintenance and renewal programme for the fabric and decoration of the premises available within the home. Requirement first issued and not met since 10th May 2005. Damaged plaster work to the wall of the activity room must be made good. DS0000062453.V258434.R02.S.doc 41 YA24 23(2)(b) 30/11/05 45 Hall Green Road Version 5.0 Page 30 42 YA24 23 Requirement first issued and not fully met since 10th May 2005. Board fitted over hole. Board not painted. The provider must review the 31/10/05 layout of the washing machines in the laundry to effect an unobtrusive use of space, safety and effective cleaning. Requirement first issued and not met since 10th May 2005. The provider must review the 30/11/05 premises against the National Minimum Standard which states 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 Requirement first made and not met since May 2005. Infection control procedures in the laundry must improve based upon advice of the Infection control nurse which must be sought. Requirement first issued and not met since 10th May 2005. The manager must ensure that temperatures (fridge and freezer) are compliant and therefore safe. Action must be taken without delay where temperatures are not compliant and action taken must be recorded. Requirement first made and not met since May 2005. 43 YA26 23(2)(a) 44 YA30 16(2)(j) 13(3) 31/10/05 45 YA30 13(3) 16(2)(j) 16/09/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 31 46 YA33 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. Requirement first issued and not met since 10th May 2005. To provide a staffing ratio of 2:1 in the community for ST with immediate effect until a written risk assessment that is discussed and agreed with the placing social worker determines otherwise. Immediate Requirement at September 2005. The manager must ensure with immediate effect that staffing levels are appropriately maintained at all times to meet the assessed needs of service users. The manager must confirm in writing to the Commission for Social Care Inspection by Friday 23 September 2005 action taken to ensure that staffing levels are appropriate and met at all times. Immediate Requirement at 31/10/05 47 YA33 18(1)(a) 16/09/05 48 YA33 18(1)(a) 23/09/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 32 September 2005. 49 YA34 19 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 Requirement first issued 10th May 2005. Not assessed at this inspection. 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. Requirement first issued and not met since 10th May 2005. 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. Requirement first issued and not met since 10th May 2005. All staff must receive infection control training with training booked by the date given. New Requirement at September 2005. All staff must receive a DS0000062453.V258434.R02.S.doc 30/09/05 50 YA34 18(1)(4) 30/11/05 51 YA35 18 30/09/05 52 YA35 18(1)(c) 30/11/05 53 YA36 18(2) 30/09/05 Version 5.0 Page 33 45 Hall Green Road minimum of six supervisions in any 12 month period. Supervisions as a minimum must cover areas outlined in Standard 36.4. New Requirement at September 2005. 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. Requirement first issued and not met since May 2005 The manager must implement a quality assurance system based upon seeking the views of service users and their representatives. New Requirement at September 2005. The Registered Manager must seek advice from the West Midlands Fire Service in relation to the sufficiency of the fire risk assessment in place. Requirement first issued and not met since 10th May 2005. A fire procedure specific to Hall Green must be in place and must be made known to staff. (This should also be included in Fire Training) New Requirement at September 2005. 54 YA37 9 30/11/05 55 YA39 24 31/03/06 56 YA42 23(4) 30/09/05 57 YA42 23(4) 30/09/05 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 34 58 YA42 23(4)(e) Fire Drills must be regularly held including all staff (and residents where possible) in accordance with the advice of the West Midlands Fire Service. Fire drills must be documented and must include the names of all taking part. New Requirement at September 2005. 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. Requirement first issued and not met since 10th May 2005. All staff must be provided with fire training twice in a 12-month period. Fire training must be booked and dates of training confirmed in writing to the Commission for Social Care Inspection by Friday 23 September 2005 confirming the names of those staff booked to attend. Immediate Requirement at September 2005. 30/09/05 59 YA42 13(4) 31/10/05 60 YA42 23(4)(d) 23/09/05 61 YA42 13(3) 23(5) The manager must take appropriate action in accordance with advice from Environmental Health Food Safety, to safeguard the health of service users DS0000062453.V258434.R02.S.doc 23/09/05 45 Hall Green Road Version 5.0 Page 35 immediately. The manager must ensure that cold storage food temperatures comply with the recommended safe range and that action is taken without delay when temperatures do not comply. Action taken must be confirmed in writing to the Commission for Social care Inspection by Friday 23 September 2005. Immediate Requirement at September 2005. 62 YA42 13(4) 13(3) A risk assessment must be undertaken in relation to infection control with control measures documented and acted upon to minimise any risks identified. New Requirement at September 2005. The manager must countersign accident records and indicate any action to be taken to minimise the risk of repetition. 31/10/05 63 YA42 13(4) 31/10/05 64 YA42 13(4) 23(2)(c) New Requirement at September 2005. Temperature guages must be 31/10/05 calibrated within the home monthly with outcomes documented. Temperature guages must be seviced annually. New Requirement at September 2005. 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 36 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 37 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 45 Hall Green Road DS0000062453.V258434.R02.S.doc Version 5.0 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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