Inspection on 02/05/06 for 45 Hall Green Road

This inspection was carried out on 2nd May 2006.

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 67 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 16/09/05

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 Key Unannounced Inspection 2nd May 2006 9:30 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 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.V290229.R01.S.doc Version 5.1 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.V290229.R01.S.doc Version 5.1 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.V290229.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16th September 2005 Brief Description of the Service: 45 Hall Green Road is a Residential Care Home providing care and accommodation 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 en suite 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. Weekly fees are £1560.00. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection for this inspection period 2006 – 2007. As it was a key inspection this means that all key National Minimum Standards were assessed. This inspection was unannounced, no one associated with the home received prior notification and were therefore not able to prepare. Two Inspectors who arrived at 9.30am carried out the inspection. The inspection finished at 7.45pm. Since the last inspection the Registered Manager has left. An Acting Manager has been appointed who was available throughout the inspection day and supported the process. Inspectors case tracked care provided to two service users by reading and assessing care documents, observing interaction between service users and staff and by talking to staff and service users. Comment cards were received from two relatives prior to inspection and their comments were used to guide the focus of the inspection. Inspectors were aware prior to inspection of a significant complaint made to the home recently, and in addition a serious allegation made against an agency staff member supplied to the home. Inspectors therefore also used this information to plan the inspection focussing on areas of specific concern. Service users experiences are mixed. Two service users who were able to indicate that they are happy but evidence shows outcomes for service users to be generally poor. The majority of service users are of one gender with the exception of one service user who, when asked what living like this is like, said that it is ‘strange’. A recent complaint alleges that one service user’s wellbeing has deteriorated in the time he has lived at the home. This is currently being investigated. The pharmacist who provides support visits to the home arrived during the course of the inspection and Inspectors took the opportunity to talk to her about how the home manages it medication. Inspectors also were able to talk to staff and where possible to some service users. One Inspector toured the premises to assess the quality of the living accommodation provided to service users. The homes progress towards meeting previous requirement notices issued by the Commission for Social care Inspection to bring about improvement was also assessed. Where urgent action was identified as required by the home, immediate requirement notices were issued at the time of inspection with dates given for compliance. What the service does well: 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 6 The premises are spacious, clean and light which provides a positive living environment for service users with autism. Staff spoke positively about the management style of the new Acting Manager finding her approach to be positive and motivating. Records indicated that gas and electrical appliances had been serviced minimising risk from such equipment. Hazardous chemicals are also managed well limiting risk to service users and staff. Discussion with a staff member showed her to have a good understanding of her role in the event of her becoming aware of the abuse of a service user in order to ensure the service users protection. Service users have access to sufficient money ensuring that their choices are not restricted by lack of money. Two Service users who were able indicated to Inspectors that they are happy. A service user was pleased to show an Inspector her bedroom. A further service user said he likes going to the pub and having contact with his family weekly. Service users, staff and the Acting Manager welcomed the Inspectors, cooperated positively throughout a long day and thanks are extended to all. What has improved since the last inspection? Since the last inspection copies of assessments undertaken by placing Social Workers have been obtained. These documents will provide staff with important information to guide care planning to meet service users needs. There is also better guidance available to support staff knowledge of service users cultural dietary requirements. Medication training has been reviewed and alternative training is being provided. Support has also been obtained from the supplying pharmacist who is now visiting regularly to provide advice to the home about the management of medication. A fire procedure has also been put in place, which better meets the needs of the home, and fire drills are being held regularly. This will ensure that staff are better prepared in the event of a fire. The lounge has been decorated and damage to walls in other areas of the home have been made good providing a more pleasant and homely environment for service users to live in. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 7 Staff spoke positively about the approach of the new Acting Manager and staff said that although motivation had dropped off recently amongst the staff group they felt that under her management motivation is improving. 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.V290229.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. Independent commissioners of service assess prospectives service users needs prior to admission. There is no evidence that the home contributes to these assessments prior to admitting service users. Service users are not assured that their needs and aspirations will be met. EVIDENCE: The Statement of Purpose requires review with the resignation of the previous manager. It is noted that Standards set out in the homes Statement of Purpose are not being achieved e.g. staff induction, supervision, complaints management, person centred planning. Community Care Assessments carried out by Social Workers prior to admission have been obtained and are on file. Information within these must be used to inform the development and detail of care plans. Pre admission assessments / documentation undertaken by the organisation remain not available and their absence hampers clarity in the event of a complaint about non delivery of service as promised pre admission. Feedback from relatives is mixed about whether sufficient information was provided about the home before moving in. There is no evidence that the Manager or provider has sent letters confirming to service users or their representatives that based upon assessed need, the home can meet service user’s needs. There is evidence that some of current service users assessed needs are not being met and this does not reassure prospective service users that their assessed needs will be appropriately met. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 10 For example one service user’s need to maintain contact with family and sibling were known at the time of admission but are not being satisfactorily met. A contract of residency was on file for the service user case tracked but the previous manager of the home was the only one to have signed this. There was no evidence that the service users representative had signed it and therefore no evidence they were aware of its contents. The Inspector asked what the arrangements are for the insurance of service users personal items. The contract urges personal responsibility for this but there is no evidence that service users representatives are aware of the need for this given that others have not signed the contract. A detailed complaint received recently by the home expresses significant concerns about the homes ability to meet the needs of a service user. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Service users individual needs and choices are poorly met. EVIDENCE: Care plans are not person centred and do not sufficiently guide staff to meet the recorded assessed needs of service users. Records for a service user case tracked show his birth date including the day month and year to be recorded differently on two occasions. Some omissions in care planning identified include contact arrangements with family members, decision making, financial decision making, how existing skills will be maintained and developed and goals to appropriately meet assessed emotional needs. Behaviour management and physical intervention guidance is inadequate, activity programming is reactive rather than proactive which is not consistent with the needs of service users with autism. A service users toileting programme has since admission contradicted assessed need, independence and dignity. The new acting manager has since corrected this practice and has put in new guidelines. The service users specific and routine health screening needs are also not addressed in the plan of care. The care plan has been reviewed twice in house by staff in August and September 2005 but not prior to this or since and this is insufficient. Two review meetings have been held 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 12 with the placing Social Worker one of which is recorded. Parents have not been able to attend these meetings, as the home does not comply with the requirements of the Disability Discrimination Act. Alternative arrangements to ensure parental participation have not been made. One relative who provided feedback did not know how service users are involved in decision-making and another felt that the service user is ‘usually’ involved not always. Records show one service to have opted not to have 2 chairs in his bedroom. It is not clear how he was able to make this choice. Poor care planning has resulted in poor outcomes for service users. For example the service user case tracked is demonstrating deteriorating behaviour, is not provided with structure based upon high levels of activity as required, is having little community access and is having infrequent contact with his family. Health outcomes are also poor and will be detailed later in this report. Service users with learning disabilities and particularly autism use behaviour to communicate feelings, needs and decisions. There is not sufficient regard for this currently. The behaviour care plan for a second service user is punitive and proposed interventions seek to marginalise the service user rather than viewing behaviours as customer feedback. Discussion with a staff member showed some understanding of the underlying causes of behaviours but behaviour triggers she described for one service user did not tally with the service users assessment and plan of care. Another staff member said she had read a behaviour care plan but couldn’t remember what it said. This was in respect of a service user who is considered to display the most challenging behaviour in the home. A pictorial book was available for use by one service user to help express food choices but it was not stored where the care plan dictated and was difficult for staff to locate upon request. The care plan states that the service user fetches this when he requires it and therefore it must be kept where he can readily access it. Risk assessments are poor. They are general based on ‘service users’ rather than the specific and variable needs of individual service users. Therefore levels of risk are not adequately assessed and control measures not appropriate. One service user has very individualised support needs in the community and the risks are individual to him. However community access has been risk assessed for ‘service users’. Nutritional risk assessments have been put in place but it is difficult to see how risk level has been accurately determined when service users have been weighed once since the home opened, in October 2005. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Lifestyle outcomes for service users are poor with particular concern being in relation to activity levels and family contact. EVIDENCE: Service users who live at Hall Green Road do not attend traditional day care. The provider is funded to provide suitable daytime activity. Service users do not attend college or other community day facilities. The Acting Manager says she is beginning to make contact with local colleges. In the meantime however activity levels, community access and contact with family are poor for the service user case tracked by Inspectors, and outcomes for him are not consistent with his statement of assessed need. For example from the 18th April to 2 May 2006 there is evidence that this service user went out on three occasions. On one day he went to 2 different swimming pools one in the morning and one in the afternoon to find them both closed on arrival. A subsequent visit to a fun fair turned into a visit to the pub because the fair was closed. This lack of planning can cause distress to a service user with autism and is contrary to this service user assessment of need which states ‘ When X goes swimming staff need to check times and the environment before going’. Records show that other activities undertaken in the main for this service user 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 14 for this time period are videos, colouring and relaxing which, whilst in line with his interests, are not sufficiently meaningful on their own and do not comply with the level and range of activity required for this young man to ensure his well being. One document that assesses ‘what I do during the day’ has been completed ‘ not applicable’ demonstrating insufficient staff understanding of the homes role and purpose. Staffing compromises activity outcomes and there is evidence that staffing levels are not being sufficiently maintained and the high use of agency staff detracts from the provision of continuity of care. The statement of need for this service user is explicit about contact with parents and sibling. The care plan does not develop this and there is no guidance about the method, manner or frequency of contact. Outcomes are therefore poor with there being recorded contact with parents once in the six weeks prior to inspection and none with a sibling. The method of recording family contact does not support easy monitoring of this. There is no reference in the daily records to evidence contact with family on this service users birthday and this outcome is unknown. There is however evidence of frequent contact with family for a second service user. This contact however is easier for the home to facilitate. Service users preferred routines are known as these are recorded and there is flexibility in routine. One service user was supported to go to bed early at her request. There is however no evidence that sufficiently structured routine is provided to promote well-being as a result of autism. The kitchen is kept locked preventing service user access. The Acting Manager is currently reviewing this practice. The Inspector spoke to one service user who said she did not have a key to her bedroom, she did not know why she did not have one and would like to have one. She also said she hadn’t voted to date and would like to. Arrangements are in hand for this and outcomes will be followed up at the next inspection to see if service users had the opportunity to vote at local elections held during the week of this inspection. Staff were observed to interact positively with service users but discussion with a staff member indicated a degree of fear of one service user which will affect interaction and outcomes for that service user. This is indicative of insufficient training and support. In a comment card to Inspectors one relative said that interaction between staff and service users is poor and not always appropriate. Fresh fruit and vegetables are not available daily, which makes it difficult to encourage one service user to eat fruit and vegetables as per his care plan. Menus are restricted to one option indicating that an alternative is not available. In practice it seems that alternatives are offered but recording systems make this difficult to evaluate and records of food to evidence individual choices are not always completed. Menus indicate that cereals and toast are the only options for breakfast every day. Systems are not in place to assess service users nutritional health and service user weights have been taken only once shortly after the previous inspection. A service user went to the chip shop on the day of inspection to fetch pie and chips for lunch and was 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 15 very pleased to have done this. When assessing service user expenditure a service user was found to have funded his lunch out which is not acceptable. The home is funded to provide lunch. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal and health care provision is poor. Lack of planning to meet the identified health needs of service users is negatively impacting on health outcomes and any health screening that is provided is poorly evidenced. Poor recording of appointment outcomes further jeopardises health care as continuity is compromised by the loss of information. EVIDENCE: Personal care including service users preferences are included in care plans in some detail and outcomes are generally good. It is pleasing to see the new Acting Manager is starting to improve toileting outcomes for one service user by basing his programme on his abilities and dignity providing an enabling service. There is evidence that a second service user is being woken by care staff 2 hourly during the night to check and provide continence care. The Acting Manager must review this to ensure that this is in line with his assessed need and ensure that the care plan contains sufficient and appropriate guidance for care staff. Personal care provided is recorded in daily records. Systems to track service users possessions must improve as current inventories have not been satisfactorily maintained and are not clear. Following a serious incident the home is now ensuring that same gender care is provided where required and control measures within the home are reinforcing this. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 17 Health records are poorly maintained and this made health outcomes, which are poor, even more difficult to evidence. The service user case tracked has complex health needs, which are clearly outlined by the Social Workers detailed assessment of need. These are not addressed in his plan of care. There was evidence of contact with a dentist and optician from letters and documentation left by these professionals. Evidence of a dental appointment for the service user case tracked was eventually found in the diary but there was no note of what treatment or advice was provided or when the next appointment is due. The optician’s document recommended the use of glasses for TV. The Acting Manager said she has not seen him wearing glasses and as she is not sure whether any glasses have been obtained intends to follow this up with staff. The Acting Manager informed Inspectors that she had accompanied the service user to an appointment with a psychiatrist and had requested referral to a range of health professionals, one of which has acknowledged the referral in writing but this appointment was not recorded. The service users Social Work assessment indicates he needs the support of a staff group familiar with epilepsy due to the need for strict monitoring of this. One staff member has received training in epilepsy. Other routine health screening has not been provided e.g. well man, hearing, chiropody etc. On the day of inspection a service user was ill and was lying on the sofa. A GP had not been called based on the telephone advice of the parent. It is positive that the service users parent was advised of his condition and that her knowledge and experience sought. Inspectors however advised the home to use its professional judgement and duty of care and to not delay seeking medical advice where there is doubt about a service users health. The visiting pharmacist identified some administrative areas that require improvement to safeguard service users during the management of medication. As at the last inspection, Inspectors found two occasions when service users had not received their medication, but on one occasion it was signed as having been given. When the error came to light staff did not implement a contingency plan to ensure the medication was given and did not seek medical advice about the omission illustrating a lack of appreciation as to the possible medical effects on health for the service users and a lack of accountability. Inspectors advised the Manager to ensure that records more clearly highlight one service users known allergy to penicillin to reduce the risk of prescription or administration in error. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 18 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): 22, 23 Complaints and protection are poorly managed. Systems are not sufficiently in place to respond to complaints and allegations robustly and therefore service users and their interests are not adequately protected. EVIDENCE: As required at the last inspection numerous complaints made have been logged. Action taken has been included and from the records it appears that issues have been mutually resolved. As this record has been completed retrospectively, dates are vague and it is not possible to evidence whether complaints have been addressed in a timely manner in accordance with the homes policy. A detailed and significant complaint, composed of many elements about the standard of service provided to a service user, was sent to the home in March 2006 at the time the new Acting Manager took up post. The Acting Manager did not disclose this complaint to CSCI in the pre inspection documentation sent for completion to the home. The complainant is not satisfied with the response. Inspection shows that the complaint has not been formally responded to. Discussion with the Acting Manager shows that she is trying to take action to address some areas of concern expressed but has not responded to the complainant outlining the investigation into their concerns and whether these complaints have been upheld or not. . Pictorial complaints guides are available on service users files but these are not available and not accessible to some service users. A complainant believes that a service user is expressing complaints through behaviours for which there is not sufficient written guidance or training with only one staff member having been provided with appropriate training. The behaviour support plan for one service user was 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 19 punitive and based upon restriction i.e. ‘being sent to a bedroom’. A staff member informed the Inspector that restraints are not used with little understanding that this can constitute restraint. A service user has made a serious allegation against a staff member since the last inspection, which is currently subject to Police investigation. The homes written adult protection procedures do not sufficiently guide action in such an event and provide misleading information. This was raised at the last inspection and has not been corrected. Subsequently action taken immediately following the allegation was not sufficiently robust with neither the Police nor Medical advice being sought in a timely effective manner. Local Authority guidance available in the home states that a medical examination should be carried out ‘as soon as possible’ and advice of police should be sought if it is not clear who should carry out the examination. Medical advice and support is now being provided. The method of informing Social Services was also ineffective meaning that there was a subsequent delay in their receipt of notification. Consideration had not been initially given to notifying the POVA list of the investigation into the staff members alleged conduct but the Inspector is assured that this has since been done. It is not known whether similar action has been considered in respect of a staff member dismissed in January 2006. Assessment of recruitment processes shows omissions and provides evidence that service users are not being sufficiently protected (evidenced later in this report) The home has not complied with a previous requirement to ensure there are 2 staff signatories in response to financial activity on behalf of service users in accordance with the provider’s own policy. Assessment of service users monies showed some inappropriate expenditure e.g. funding a lunch, and service users were found to be meeting the cost of staff theatre tickets when escorting service users. Records of financial activity are robust with receipts kept and assessment showed balances to tally with cash in hand held on the premises. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The premises are adequate, being spacious and generally safe. Heavy usage has lead to a rapid deterioration in décor, furnishings and fittings and the renewal and maintenance programme is not sufficiently robust to ensure that the premises remain of good quality. Prompt attention is required to prevent further decline. EVIDENCE: The suite in the lounge is heavily stained and not appropriate for heavy use. The one settee is in addition damaged. The covers do not fit as they have shrunk following washing. There is a hole exposing the inner foam on the arm. This raises concerns about the possibility of compromised infection control, fire retardency and safety given that Hall Green is home to service users with a high degree of needs and behaviours. One service user for example has begun shredding and picking clothing and wall plasterwork and there is concern about his assessed tendency to consume such materials. The Acting Manager has raised concern upon taking up post about the state of this furniture but been advised that there is no money for replacement in this financial year. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 21 Some bedroom carpeting is stained as is the dining room and corridor paintwork. A carpet cleaning and renewal programme is required. The provider has been aware since the admission of one service user of the need to ensure that the building is wheelchair accessible to enable family visits. This has not been addressed in 18 months although the new acting manager has obtained and submitted quotes for consideration. Assessment of a service users bedroom showed his clothes to be stored in accordance with the care plan based upon the risk of him destroying his clothes. Systems to ensure the safety of hot and cold food storage continue to require improvement to ensure the protection of service users health and well-being. Similarly some omissions in infection control need addressing e.g. the provision of protective clothing and paper towels in all key areas, laundering of mop heads, wall finishes and storage in the laundry to ensure effective cleaning and the control of cross infection. Dried foods are not being appropriately stored increasing the risk of the spread of infection from infestation from pests. Records show one service to have opted not to have 2 chairs in his bedroom. It is not clear how he was able to make this choice. On arrival the Inspectors found the central heating not working, it had developed a fault that morning. Engineers arrived and rectified the problem on the same day. The planned maintenance and renewal programme for the fabric and decoration of the premises is insufficient and not meeting the needs of the home 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Systems to safely recruit, train and supervise staff are poor. Staffing ratios are not maintained. Systems are not in place to ensure that service users are always supported by sufficient fit and well trained staff. Service users safety and welfare is therefore compromised. EVIDENCE: Risk assessments are unsatisfactory as they are general, referring to risk to ‘service users’ in the community and not to risks associated with the needs of specific individuals. The Acting Manager is unclear about staffing levels that she should be providing in the community for one service user. She states that she has been providing staffing at a ratio of 2:2 but believes he requires 2:1. There is no evidence of any progress made since the beginning of the placement that could indicate a need to reduce the staffing ratio in the community and no evidence that this change has been agreed with Social Services. Clarity is required to protect his safety and to ensure that the home is meeting his assessed needs. 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). Assessment of the rota at the previous inspection, September 2005 shows that this minimum-staffing ratio had not been maintained particularly after 3pm and when staff phone in sick or are on annual leave. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 23 Consequently an immediate requirement was issued in respect of staffing levels in September 2005. This inspection showed that difficulties remain. Two staff phoned in sick for the afternoon shift on the day of inspection. Therefore five staff (plus the Manager who was engaged in the process of inspection) was on duty from 3pm instead of seven staff. An agency was contacted at 2.30pm and by 5.30pm had not responded. An existing staff member was contacted who arrived to cover at 6pm. The Manager in addition was obliged to stay and cover until 10.00pm. Therefore from 3pm until 6.00pm the home was understaffed. Assessments of activities lead to inspection of the shift plan for the afternoon. The service user being case tracked was not allocated a staff member to provide his one to one support during the afternoon as a direct result of staff shortages. His assessment and care plan indicate the need for structure, routine and high levels of activity to manage behaviour. Outcomes indicate this need is not being met and that his behaviour is deteriorating. This amongst other issues is currently subject to a formal complaint. There continues to be a lack of clarity about the number of weekly care hours required. Two figures exist - 780 hours and 820 hours. The Acting manager said that 780 hours are being provided. Information provided pre inspection show that the home has 570 contracted hours, over 200 short of that required hence the high use of agency staff. Several staff have been recruited and are awaiting clearance, the Inspectors were informed. A service user has made a serious allegation against a staff member supplied to the home by an agency and this allegation is subject to police investigation currently. Recruitment practice within the home particularly including that of agency staff was therefore inspected. There is evidence that some agency staff have not received a POVA check, potentially because C.R.Bs are more than 12 months old. Both statements from the agency state that these staff have no POVA check. In addition statement sheets from the agency do not contain the date of the CRB or POVA check in order for the Acting Manager to verify that these checks are less than 12 months old as per Department of Health guidance. A staff member has been dismissed since the last inspection. Disciplinary records were available. It is not known whether the provider has considered its duty to refer this staff member to the POVA list of people unsuitable to work in the care profession to protect service users in other home. The provider has assured CSCI that checks in relation to the suspended agency staff member are appropriate. The provider is further required however following the outcomes of this inspection to verify that recruitment checks (POVA and CRB) in place for the agency staff member subject to allegation are less than 12 months old. The outcome must be confirmed to CSCI in writing. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 24 Training is poor. An audit of staff training during the inspection showed that there are six staff who have not done any training at all including mandatory training. Information available from the agency in respect of the staff member subject to suspension and investigation suggests that this individual has received no training. Five staff only out of 19 have done adult protection training. Two staff members have completed NVQ 2 with 5 currently undertaking it leaving the home far short of the 50 national target. Little training has been provided to equip staff to understand the needs of service users e.g. behaviour management training, epilepsy and autism awareness or disability and equality training. One staff member has received induction training to the required national standard. Systems to support training development have not been kept up to date. An untrained staff group cannot effectively meet vulnerable service users complex needs. The Acting Manager stated that no progress has been made towards the goal of providing regular supervision for staff. She is aware of the need for this and intends to start this when she has been in post for two months. It is her intention to arrange supervision training for senior staff so that responsibility for providing formal supervision can be cascaded. Relatives opinions about whether staff treat service users well is mixed with one stating service users are ‘always’ treated well and the other commenting ‘sometimes’ adding that interaction is often poor and not always appropriate. Feedback from the relatives who responded was not positive about whether care staff listen. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 25 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): 37, 39, 42 Poor outcomes detailed throughout this report indicate weaknesses in management, which the new Acting Manager is hoping to reverse. The health, safety and welfare of service users have not been proactively managed and there is currently the potential for harm. EVIDENCE: Registered Manager and the Deputy Manager have left since last inspection. An Acting Manager with suitable prior experience and who is working towards required qualifications has been recruited and now intends to apply for registration, which she must do without delay. She is aware of the homes strengths and deficits and realises that there is a lot to achieve. The Deputy manager post has also been filled. In five weeks since she took up post she has not received formal supervision but feels she has been well supported by phone. Quality assurance systems based upon service user and other third party feedback are not in place and no progress has been made to support the home 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 26 and provider to assess and respond to its own performance. This is a significant weakness in management systems and undermines the homes potential for improvement. Service and maintenance records were largely available and up to date with the exception of water temperature checks and water hygiene services e.g. there was no evidence of chlorination or legionella safety checks. This largely assures service users and relatives that risk from equipment and fixtures is minimised. Risk is however generally not managed well as risk assessments are poor. An example being a risk assessment for slips trips and falls includes control measures for fridge and freezer temperatures. A risk assessment in respect of the laundry is also muddled and unclear. There are few recorded accidents but assessment of other documentation showed that incidents and accidents are happening but are not being recorded. This restricts accountability and prevents the identification of accident trends, concealing the need for potential action to further safeguard service users and staff. There was a well-stocked and audited first aid box and staff knew where it is stored. Fire training was subject to the issue of an immediate requirement notice at the previous inspection, September 2005. Fire training was assessed at this inspection and there is no evidence that action has been taken to meet the previous immediate requirement notice issued. There is evidence of fire training having been provided to some staff in April and May 2005 and to a minority of staff in March 2006. There is no evidence that any fire training has been provided to eleven staff. The Acting Manager said that fire training has been organized to take place imminently for 6 staff but it was not known which six staff are to undergo this training. In addition to those for whom there is no evidence of training, training provided in April and May 2005 is now due for renewal. There are an unacceptable number of outstanding and new requirements for improvement, which indicates concern about how the home has been managed. Staff said that they haven’t previously had access to inspection reports about the homes performance. This makes it difficult for staff to understand what needs to improve and why. It also denies them the opportunity to know which aspects of their performance are positive. It is of particular concern that previous immediate requirements have been reissued at this inspection. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 1 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 X 15 1 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 2 X 1 X 1 X X 2 X 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 28 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 (new Manager and staffing) New Requirement at this inspection, May 2006. Timescale for action 31/07/06 2 YA2 14 Copies of all assessments undertaken pre admission must be obtained and held on file. New Requirement at September 2005. Not Met at May 2006. 30/06/06 3. YA2 14 To review the role of the 31/08/06 Registered manager in relation to carrying out preadmission assessments. New Requirement September 2005 Not assessed at May 2006 – no new admissions 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 29 4. YA3 14 The Registered Manager 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. Not met at May 2006. 30/06/06 5. YA4 12(2)(3) 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. Requirement first issued and not met since 10th May 2005. Not assessed at May 2006 as no new admissions. 31/05/06 6. YA6 15 To write and implement a care plan by Friday 23 September 2005 for S.T based upon assessed needs. Immediate Requirement at September 2005. (ST not case tracked at this inspection) 31/05/06 7. YA6 15 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, social, nutrition, healthcare, financial management, decision DS0000062453.V290229.R01.S.doc 30/06/06 45 Hall Green Road Version 5.1 Page 30 making, restrictions, contact with family, Requirement first issued and not met since 10th May 2005. Not met at May 2006. 8. YA9 13(4) 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. No new admissions at May 2006 9. YA9 13(4) 31/05/06 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. At May 2006 – risk assessments based upon known need remain insufficient. 10. YA9 13(4) Risk assessments must also be 31/05/06 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. At May 2006 action taken but risk assessments are of poor quality. 11. YA9 13(4) To write and implement risk DS0000062453.V290229.R01.S.doc 31/05/06 31/05/06 Page 31 45 Hall Green Road Version 5.1 assessments by Friday 23 September 2005 for ST to minimise all assessed risk. Immediate Requirement at September 2005 (ST not case tracked at this inspection – unable to verify if implemented) 12 YA9 13(4) Service users risk assessments 30/05/06 must be individualised. New Requirement at May 2006. Service users must be enabled to vote if they wish at next election (4.5.06). This must be evidenced. Requirement first made May 2005. Progress noted at May 2006 to support wishes to vote – polling cards obtained etc. To assess at next inspection. 14. YA13 16(2)(m)(n) The manager must ensure that 31/05/06 information and advice are available about local activities, support and resources. Requirement first issued 10th May 2005. Not assessed at this inspection 15. YA14 15 Written activity plans for each individual Service User must be developed and implemented based upon assessment of need. Outcomes must be monitored and evidenced Requirement first issued 10th May 2005. Not Met at 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 32 13. YA13 12(3) 31/05/06 30/06/06 May 2006. 16 YA15 12, 15 Arrangements for contact with 30/06/06 family must be assessed for all service users and the detail recorded in care plans – how, who, when and where including stipulated frequency of contact as agreed. This must then be implemented and records established for monitoring outcomes. New Requirement at May 2006. Nutritional assessments must 30/06/06 be undertaken for each service user, kept under regular review and must be acted upon where risk is identified. New Requirement at September 2005. Not met at May 2006. 18 YA18 12, 13 The Acting Manager must 31/05/06 review the regularity of nighttime continence care to ensure that this is in line with assessed need and ensure that the care plan contains sufficient and appropriate guidance for care staff. New Requirement at May 2006 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. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 33 17. YA17 Sch 3 / 4 19. YA19 13 30/06/06 Not Met at May 2006. 20. YA19 12, 13 The Registered Manager must ensure that all Service Users are offered minimum annual health checks for vision, hearing, and medication. The manager must ensure that should a Service User decline to attend screening offered that this is recorded. Requirement first issued 10th May 2005. Not Met at May 2006. 31/08/06 21. YA19 12, 13 Service users must be regularly weighed with outcomes recorded and action taken where necessary. New Requirement at September 2005. Not Met at May 2006. 31/07/06 22 YA19 13 The Acting Manager must follow up the outcome of OB’s optician appointment e.g. the recommendation to wear glasses for TV. New Requirement at May 2006. 31/05/06 23. YA20 13(2) 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 User The manager must implement a recorded system of auditing 31/05/06 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 34 medication records. Requirement first issued 10th May 2005. Not Met at May 2006. 24. YA20 13(2) The Medication Policy must 31/08/06 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. Not Met at May 2006. Manager has in the meantime ensured this guidance is on medication cabinet. 25 YA20 13(2) The Acting Manager must take steps to ensure that all staff know what action to take in the event of a medication error / omission to ensure the welfare of the service user. Action taken must be evidenced. The Acting Manager must ensure that service user records effectively highlight service users allergy to penicillin. New Requirement at May 2006. 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. DS0000062453.V290229.R01.S.doc 31/05/06 26. YA22 22 31/05/06 45 Hall Green Road Version 5.1 Page 35 Requirement first issued and not met since 10th May 2005. Not Met at May 2006. 27 YA22 22 The Acting Manager must formally investigate the complaint submitted to the home in a letter dated March 19th 2006 and must respond to the complainant indicating whether each area of complaint is upheld or not upheld, part upheld, unresolved etc. A copy must be sent to CSCI. Certificates to evidence 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. Not Met at May 2006. 29. YA23 13(6) 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. Not met at May 2006. 30. YA23 13(6) All staff must receive adult protection training. New Requirement at September 2005. Not Met at May 2006. 31/08/06 30/06/06 31/05/06 28. YA23 18(1)(c) 31/08/06 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 36 31. YA23 13(6) 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. Not Met at May 2006. 31/05/06 32 YA23 13(6) Behaviour management guidelines must be reviewed for all service users so that they appropriately guide staff intervention based upon up to date good practice e.g. known behaviour triggers, deescalation, positive behaviour, ability and willingness. These guidelines must be made known to staff. Input from Psychology services must be obtained. New Requirement at May 2006. Service user inventories of personal possessions must be reviewed to ensure clarity and must be accurately maintained. New Requirement at May 2006. The provider must write to CSCI to explain whether consideration has been given to referring the staff member dismissed in February 2006 to the national POVA list, why and the outcome. New Requirement May 2006. Service users must not subsidise meals that the DS0000062453.V290229.R01.S.doc 31/05/06 33 YA23 13(6) 30/06/06 34 YA23 13(6) 30/06/06 35 YA23 13(6) 30/06/06 45 Hall Green Road Version 5.1 Page 37 provider is funded to provide. Service users must not pay any staff expenses. The Acting Manager must investigate and ensure that all inappropriate expenditure is refunded to service users. The outcome must be confirmed to CSCI in writing. 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. Not Met at May 2006 37. YA24 23 There must be a written 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. Not Met at May 2006 – A written planned maintenance and renewal programme for the fabric and decoration of the premises including a programme of carpet cleaning must be submitted to CSCI with target dates. New Requirement at May 2006. 38 YA24 23(1)(a) The provider must ensure that DS0000062453.V290229.R01.S.doc 36. YA24 16(2)(c) 31/07/06 30/06/06 30/09/06 Page 38 45 Hall Green Road Version 5.1 23(2)(a) the premises are accessible in accordance with the Disability Discrimination Act, service users right to have contact with family and in accordance with the aims and objectives of the home as set out in the Statement of Purpose e.g. ‘fully adapted’, ‘open door policy’ ‘ close liaison with family etc. To write to CSCI by 9 May 2006 with an action plan including target dates for the replacement of the affected settee (To further ensure that consideration is given in the meantime to any risks posed by the settee based upon advice from relevant agencies including the Fire Service / Environmental Health and that steps are taken and recorded to reduce any risks identified) Immediate Requirement at May 2006. 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. Not Met at May 2006. 09/05/06 39 YA24 23 40 YA30 16(2)(j) 13(3) 31/07/06 41. YA30 13(3) 16(2)(j) The manager must ensure that 02/05/06 temperatures (fridge and freezer) are compliant and therefore safe. Action must be taken without delay where temperatures are not compliant and action taken DS0000062453.V290229.R01.S.doc Version 5.1 Page 39 45 Hall Green Road must be recorded. Requirement first made and not met since May 2005. Not Met at May 2006 42. 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. At May 2006 lack of clarity remains. One document indicates 820 hours required, another 780. 43. YA33 18(1)(a) 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. At May 2006 lack of clarity remains re staffing level required in community for this resident. 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 40 31/05/06 09/05/06 44. YA33 18(1)(a) Immediate requirement issued May 2006 – response due by date given 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 September 2005. Not Met at May 2006. Immediate requirement repeated at MAY 2006 – response due by date given 09/05/06 45 YA33 18(1)(A) 13(4) To ensure that sufficient staff are on duty at all times to meet the assessed needs of service users To ensure that staffing contingencies are sufficient to cover staff absence To notify CSCI on each occasion that staffing levels are not met To clarify staffing levels required in the community for service user ST, seeking advice from Social Services and subject to clear individualised risk assessment. To confirm action taken, action 02/05/06 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 41 plans and outcomes in respect of staffing levels to CSCI by 9th May 2006. Immediate Requirement at May 2006. The manager must ensure that 31/05/06 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 Met at May 2006. 47 YA34 19 To cease the employment of any agency staff who have not received a POVA check immediately within one day of inspection. To cease immediately within one day of inspection the employment of any agency staff who have not received a CRB and POVA check within the last 12 months To confirm action taken in writing to CSCI by 9 MAY 2006. Immediate Requirement at May 2006 The provider is required to verify that recruitment checks (POVA and CRB) in place for the agency staff member subject to allegation are appropriate and less than 12 DS0000062453.V290229.R01.S.doc 46 YA34 19 03/05/06 48 YA34 19 30/06/06 45 Hall Green Road Version 5.1 Page 42 months old. The outcome must be confirmed to CSCI in writing. New Requirement at May 2006 Each staff member must be 30/06/06 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. Not Met at May 2006. 50. YA35 18 LDAFF induction and foundation training must be provided to new unqualified social care staff. This training must be provided within approved timescales e.g. 6 weeks and 6 months. Requirement first issued and not met since 10th May 2005. Not met at May 2006. 51. YA35 18(1)(c) All staff must receive infection control training with training booked by the date given. New Requirement at September 2005. Not Met at May 2006. 52 YA35 18 All staff must receive all mandatory training and specific training to support their knowledge of service users individual needs e.g. epilepsy, communication, and DS0000062453.V290229.R01.S.doc 49. YA34 18(1)(4) 31/05/06 30/09/06 31/07/06 45 Hall Green Road Version 5.1 Page 43 autism awareness, disability equality, challenging behaviour. A robust training programme supported by up to date group and individual training matrices must be implemented and managed to ensure positive training outcomes. All courses must be booked for all staff by the date given New Requirement May 2006. All staff must receive a 30/09/06 minimum of six supervisions in any 12-month period (September 2005 – September 2006) Supervisions as a minimum must cover areas outlined in Standard 36.4. New Requirement at September 2005. Not Met at May 2006. 54 YA37 9 The provider must ensure that an application to register a manager in respect of Hall Green Road is submitted to CSCI by the date given. The manager must implement a quality assurance system based upon seeking the views of service users and their representatives. New Requirement at September 2005. Not Met at May 2006. 56. YA42 23(4) The Registered Manager must DS0000062453.V290229.R01.S.doc 53. YA36 18(2) 30/06/06 55. YA39 24 30/09/06 30/06/06 Page 44 45 Hall Green Road Version 5.1 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. At May 2006 - Letter sent to Fire Service. Response not specific to Fire risk assessment. 57. YA42 13(4) The manager must ensure that 31/05/06 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. Not Met at May 2006. 58. YA42 23(4)(d) All staff must be provided with fire training twice in a 12month 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. Not Met at May 2006 – second immediate requirement issued. Response due by date given 59 YA42 23(4)(d) To write to CSCI by 9 May DS0000062453.V290229.R01.S.doc 09/05/06 09/05/06 Version 5.1 Page 45 45 Hall Green Road 2006 explaining why there is no evidence of fire training as per previous immediate requirement To ensure that all staff receive appropriate fire training To provide an action plan to CSCI with target dates for fire training for all staff To ensure that the action plan provided to CSCI considers how the regular provision of fire training to all staff will be ensured. 60. 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 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. Not met at May 2006. 61. 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. DS0000062453.V290229.R01.S.doc 02/05/06 30/06/06 45 Hall Green Road Version 5.1 Page 46 New Requirement at September 2005. Not Met at May 2006. 62. YA42 13(4) The manager must countersign accident records and indicate any action to be taken to minimise the risk of repetition. New Requirement at September 2005. Not Met at May 2006. 63. YA42 13(4)23(2)(c) Temperature guages must be calibrated within the home monthly with outcomes documented. Temperature gages must be serviced annually. New Requirement at September 2005. Not Met at May 2006. 64 YA42 13(4) Water temperature checks must be resumed. New Requirement at May 2006. Evidence must be available that the homes water supply has been tested for legionella. A water chlorination certificate must be available. New Requirement at May 2006. Risk assessments in place in respect of the environment must be reviewed to ensure they meet all aspects of risks and to ensure clarity. New Requirement at May 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 47 31/05/06 31/05/06 09/05/06 65 YA42 13(4) 30/06/06 66 YA42 13(4) 31/05/06 2006. 67 YA42 17(1)(a) Sch 3 (3)(j) All accidents, injuries and incidents must be recorded. New Requirement at May 2006. 09/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations It is strongly recommended that copies of residency contracts are issued to service users and or their representatives for signing with signed copies being issued to those who sign and a further copy to be retained on the premises 45 Hall Green Road DS0000062453.V290229.R01.S.doc Version 5.1 Page 48 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.V290229.R01.S.doc Version 5.1 Page 49 - 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!