Inspection on 19/07/06 for 46 Sedgley Road

This inspection was carried out on 19th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Sedgley Road 17/07/07

46 Sedgley Road 19/10/05

46 Sedgley Road 09/05/05

46 Sedgley Road 09/11/04

46 Sedgley Road 05/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 46 Sedgley Road Swan Village Care Services Ltd Woodsetton Dudley West Midlands DY1 4NG Lead Inspector Jayne Fisher Unannounced Inspection 19th July 2006 09:45 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Sedgley Road Address Swan Village Care Services Ltd Woodsetton Dudley West Midlands DY1 4NG 01902 421938 01902 421941 swanvillage1@aol.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Swan Village Care Services Limited Ms Eunice Harrison Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 October 2005 Brief Description of the Service: 46 Sedgley Road is a privately owned care home, which has been registered to provide care for a maximum of five adults who have learning disabilities. The home is situated in a residential area of Sedgley and has a regular public transport system that enables easy access to Dudley and Wolverhampton town centres and places of local interest such as Dudley Zoo, the Black Country Museum and the local nature reserve. The home has its own transport. There are car-parking facilities at the rear of the premises. Sedgley Road comprises two floors; on the ground floor are a lounge, kitchen/dining area and a single bedroom with adjacent shower room. The first floor has four single bedrooms and bathroom. The home does not provide any lift facilities and therefore is not suitable for service users with physical disabilities. Visitors are welcomed at any reasonable time. They are requested to sign the visitor’s book in the hall, on their arrival and departure. A statement of purpose and service user guide are available to inform residents of their entitlements. Information regarding fee levels were provided in April 2006 which are between £700 - £1067 per week. There are additional charges for toiletries and hairdressing. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days between 09:45 a.m. and 19:00 p.m. hours on the first day, and 09.00 and 12:00 hours on the second day. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: interviews with the manager and three staff. Two residents completed questionnaires with the aid of the manager. Where possible, responses were discussed with residents. All of the four residents were at home during varying stages of the inspection. Formal interviews were not appropriate with all residents. Therefore the inspector relied upon observations of body language, eye contact, gestures, responses and other observations of interaction between staff and residents. One resident was happy to be interviewed but another declined to participate. Residents’ care plans were examined and care was case tracked by reading and assessing care documents, observing interactions and by talking to staff and chatting to a resident. The environment was assessed by touring the premises. Staff personnel files were accessed and a sample of maintenance and service records were examined. Other documentation was reviewed in order to evaluate how the home is being run. Since the last inspection the manager has now been registered and there has also been a change in ownership and a new larger company has taken on the running of the home. What the service does well: Residents are supported by a qualified, stable and enthusiastic staff team and manager. Residents are encouraged to be independent and as a result some residents go out unaided to do their own shopping and visit places of interest, manage their own money, make their own drinks and snacks. Daily routines are flexible and residents can get up and go to bed at a time of their own choosing. Other residents are more dependent and staff offer support in a manner which respects their dignity and privacy. Staff help residents to maintain important links with their families. There is a varied and well balanced diet and residents help plan the menu and can choose alternatives if they wish. There are good systems in place to support the health care needs of residents. Arrangements are in place to protect residents from abuse and encouragement and support is given if they wish to raise any concerns. Systems are in place to promote residents’ health, safety and well being. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 6 The staff team is supported by a dedicated and caring manager. The atmosphere was relaxed and friendly throughout the inspection; residents looked comfortable in their surroundings and responded positively to guidance and interaction given by staff. What has improved since the last inspection? 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. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 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 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 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): 1, 2 The overall outcome for this group of standards is judged to be good. There is a range of comprehensive information for prospective and existing service users regarding how their assessed needs are going to be met and the services provided. EVIDENCE: Since the last inspection visit the manager has ensured that the service user guide has been reproduced in formats suitable for residents. On examination a pictorial guide gives sufficient information regarding the service, for prospective residents to be enabled to make informed choices about whether or not they wish to live at the home. The manager states that the service user guide has also been produced in a video format but this has yet to be downloaded onto disk. The service user guide written in plain English now includes details of fees charged as previously requested. However, this document requires updating in a number of areas since it was first established in 2004. For example, it contains details of the former proprietors and mentions training for staff that is to be achieved by 2004. There are no details supplied with regard to termination of the contract and period of notice etc. There have been no new admissions to Sedgley Road since the last visit. There is currently one vacancy. During interviews the manager demonstrated a responsible approach to new admissions confirming that her main priority was to ensure compatibility with existing residents. There is a comprehensive 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 9 admission tool. The service co-ordinator has created an extra section on compatibility as seen at another establishment. There are a number of assessment tools as seen in residents’ case files. As good practice, residents’ needs are periodically reassessed using these tools for example with regard to independent living skills. As required the manager has now ensured that service users have a contract/terms and conditions of residency which were available for inspection. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The overall outcome for this group of standards is judged to be adequate. Care planning, risk assessments and strategies for enabling residents in decision making are improving although further progress is needed in order for residents to be able to make known their wishes and aspirations through different person centred planning styles. EVIDENCE: A sample of care plans were examined. Considerable improvements have taken place in care planning and it is pleasing to see that staff, as well as the manager, have been involved in reviewing and drawing up new plans. They are to be commended for their efforts in improving standards in this area. During interviews staff demonstrated suitable knowledge regarding care plans although still need to fully familiarise themselves with all areas (for example likes and dislikes relating to food). Care plans in place now cover a wide number of subjects including personal care, health, social and emotional support and independent living skills. There are only a couple of omissions. For example, one resident has continence problems but there is no care plan as to how this is managed. Neither was 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 11 there a specific care plan in place with regard to epilepsy. As discussed with the manager any restrictions or limitations on choice must receive an appropriate care plan and risk assessment (such as the provision of monitor in the resident’s bedroom which compromises privacy and dignity, or the current need to have an escort in the community). ‘Fine tuning’ is necessary in respect of some care plans as interviews with a coworker revealed that varying strategies and approaches are used to support the resident which aren’t always recognised in the care plans. For example, there is a comprehensive care plan in place for one resident’s support given with regard to helping manage finances. However there is one particular issue which is not identified and varying strategies may be beneficial such as money recognition skills training. There were three care plans in place with regard to one resident’s challenging behaviour which is slightly confusing. More details are needed in residents’ care plans for challenging behaviour for example, detailing the types of behaviours and explaining what the ‘warning’ signs are and techniques employed to ‘minimise attention seeking’. Good attempts have been made to involve residents in care planning and there are some elements of care plans which have been produced in pictorial formats. Care plans are read to residents and they can sign as an indication of their agreement. However, as discussed with the manager, different person centred planning styles should be explored in order to enable all residents to participate and be enabled to make their aspiration and wishes known and to be able to demonstrate what is important to them. It is pleasing to see that communication passports are currently in the process of being drawn up. This has nearly been completed for one resident. The manager demonstrates a proactive attitude towards advocacy and has actively sought support from advocacy services and has been successful for two residents. The manager has made good attempts at involving residents in recruitment and selection of new staff as previously required. It is recommended that residents are offered opportunities to be involved in the running of the service at a strategic level, for example representation in management structures. During interviews a member of staff gave good examples of how he wanted to involve residents in quality assurance. On the whole there are good risk assessments in place which cover a range of topics. There were detailed risk assessments seen for residents’ challenging behaviour. Only slight improvement is necessary. For example, ensuring that risks are assessed with regard to travel on the home’s transport, bathing and water temperatures, incontinence and epilepsy. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The overall outcome for this group of standards is judged to be adequate. Improvements are needed in activity planning and recording. Staffing levels compromise residents’ choices with regard to activities including community based outings. Residents are supported to maintain important links with their families and friends. Residents are offered a healthy and balanced diet. EVIDENCE: Two residents attend formal day care provision. Two residents at present have no day care or employment. Interviews with staff and management confirmed that good efforts are being made to source employment and educational opportunities for these residents which was evidenced through examination of documentation. During interviews one resident admitted that they were ‘bored’ during certain parts of the day time. There are individual activity plans in place for all residents. These were established twelve months ago by a previous manager and require review as 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 13 they do not always accurately reflect the current activities being undertaken. It is noted that in some instances activities planned are similar for all residents and were therefore not individualised. For example, on Saturday and Sunday evenings the same activity is planned for residents. Staff stated that this is due to the fact that there are only two staff on duty. As there are only two staff, outings within the community particularly at weekends are limited especially as one resident now has increased dependency and requires an escort. Residents individual preferences can therefore not be accommodated. All staff who were interviewed felt that more staff were needed to facilitate choice for residents with regard to activities. Case tracking activities proved difficult due to poor recording. There are two types of recording sheets for activities both of which were not being consistently completed. Despite this it was pleasing to hear the efforts made by staff to provide residents with entertainment. For example, themed days and nights which is commendable. Staff provide support for residents to maintain links with families. This was confirmed during an interview with one of the residents. There were records and care plans to demonstrate how this is undertaken. The manager has also been successful in supporting one resident to re-establish links with her family which is admirable. Observations during the inspection confirmed that staff fully respect residents’ rights to privacy and dignity. For example, staff were seen to knock on residents’ bedroom doors before entering and ensuring that they were asked if they were suitably clothed before offering assistance in an emergency. A resident who was interviewed stated that staff ensured she could spend time alone with another resident as per agreement in care plans. She stated “I can go out when I want to” and chatted about shopping centres she liked to visit. Examination of the menu plan and records of residents’ choices confirm that a varied and well balanced diet is provided. However, residents’ individual food records need to be more consistently completed. The manager explained that menu planning is carried out weekly with residents participating in this process however no records are maintained of this consultation. It was pleasing to see records of residents’ likes and dislikes contained within their case files. Nutritional care plans are in place but require more detail particularly with regard to problems identified on behalf of some residents. Nutritional screening tools are in place and it is recommended that residents’ body mass index is calculated and included in care plans. During interviews a resident stated that she could make her own drinks and snacks and stated that the food was ‘nice’ and she could ask for alternatives (which was confirmed on examination of food records). On the first evening of the inspection visit staff were preparing a home made chicken curry which smelt appetizing and one resident confirmed that she liked to eat curry and was looking forward to her dinner. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The overall outcome for this group of standards is judged to be adequate. Generally service users receive personal support according to their preferences. There are good systems in place with regard to ensuring health care needs are recognised and treated. The arrangements for the control and administration of medication require improvement in order to offer greater protection to residents. EVIDENCE: A resident who was interviewed stated that she could go to bed when she wanted and added that “I like living here, staff are nice”. Care plans are in place with regard to how residents receive personal support. The ‘priority screening for healthcare’ booklets contain information regarding residents’ preferred bed times (although these now require updating). Consideration must be given to residents’ preferences as to whether male or female staff support them and this must be recorded in care plans. All residents are receiving hourly night checks. As discussed with the manager, this must be reviewed. If there is a justified medical or behavioural reason for this level of monitoring it must be agreed with the resident and a multi-disciplinary team with a relevant care plan in place. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 15 There was ample evidence to confirm that the health needs of residents are a priority with staff. Residents receive support to access regular routine health checks including hearing tests, eye tests, chiropody and visits to the dentist. The manager demonstrates a proactive attitude and is persistent in ensuring that residents have access to health care resources. For example, it was noted that residents are receiving two yearly instead of annual ophthalmology checks. This was immediately actioned by the manager. Residents receive support from specialists including psychiatry and occupational therapists. Staff are currently working with the local Intensive Support Team (psychology service) to draw up management behavioural guidelines for residents with identified problems. Only one slight improvement is needed. Procedures and care plans need to be introduced to supplement annual or three yearly well person checks through a programme of education for residents regarding self examination, and awareness for staff in observing any physical abnormalities. Whilst there are some good systems in place with regard to the control and administration of medication, there are some elements of practice which are unsafe. For example, it was pleasing to see that consent has been discussed with regard to residents’ receiving medication, copies of prescriptions are retained and case files contain details of medication. There are good records of receipt and disposal of medication. Examination of medication administration record (MAR) sheets reveals improvements are needed. For example, these were viewed after 5.00 p.m. however, the morning medication on behalf of one resident had not been recorded as given or refused. Indomethacin had been signed for at 5.00 p.m. but on checking, had not been given. It was noted that staff had signed on the wrong day with regard to one resident’s medication and as a result were a day in front of the actual medication cycle. A serious concern was identified with regard to covert administration of medication. Staff are undertaking covert administration in respect of one service user. There is no care plan in place. During interviews staff and management gave differing responses as to how they were undertaking this task and the approaches used. For example, one staff member stated that 6 tablets were to be placed in the first spoonful of food, another stated that tablets were placed in two or three spoonfuls or inserted into differing types of hot or cold food. The manager could not locate evidence that this had been discussed within a multi-disciplinary team and consent and approval had been obtained, (which was said to have been carried out by the previous manager). The resident does refuse to eat meals particularly if tablets are noticed. There are no guidelines for staff as to how many refusals are acceptable before further medical advice is sought. An Immediate Requirement was issued to address this issue. Other deficiencies noted are contained within the Requirements section of this report. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The overall outcome for this group of standards is judged to be good. There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. There are procedures in place to safeguard service users from abuse, neglect and self harm. EVIDENCE: The home has a comprehensive complaints system which has been reproduced in a pictorial format for residents; a copy is contained within their case files. It was refreshing to see that how to make a complaint is a topic discussed at service user meetings. During interviews one resident was clear about who they should speak to if they are unhappy. During interviews staff gave good examples of how they would support residents in making complaints. There have been no complaints received about the service during the last twelve months. The majority of staff have received training in vulnerable adult abuse awareness. During interviews staff gave good responses as to how they would deal with any potential incidents of abuse. There are copies of relevant documentation on the premises in relation to adult protection. An allegation which could be construed as potentially abusive was made by a service user during the inspection. The manager was helpful and supportive in encouraging the resident to bring this to the attention of the inspector. Immediate and appropriate action was undertaken by the manager. During interviews one resident stated that they felt safe living at the home when asked. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 17 Service users can display challenging behaviour (see further comment in standard 33 with regard to staffing levels), during interviews staff gave good examples of this is managed and there is on-going support from psychologists. As already stated care plans do require further details and it is also recommended that Antecedent behavioural consequence (ABC) charts are reinstated on behalf of one resident. The majority of staff have received training in understanding and managing challenging behaviour. On examination there are good procedures in place with regard to service users’ money and financial affairs. It was encouraging to find that where possible, residents take responsibility for managing their own finances including collecting money from the post office. There are up to date personal expenditure sheets and on sampling monies balanced correctly with amounts detailed on records. There is daily auditing by senior staff. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The overall outcome for this group of standards is judged to be adequate. Whilst the premises continue to be homely and comfortable, some repairs and redecoration is required. Infection control practice needs improvement in order to offer greater protection to residents from infection. EVIDENCE: A tour of the premises was undertaken. It was pleasing to see that action had been taken to address most of the previous requirements. Communal areas are comfortably furnished, bright and airy. Those residents’ bedrooms which were viewed were seen to be suitably furnished and decorated with evidence of residents’ personal belongings and possessions. It was pleasing to see the efforts made by staff to make the small garden area more attractive and appealing for residents. Carpets in communal areas remain stained and the outside of the premises still requires redecoration and repair. New items identified at this visit include: - lack of suitable garden furniture - cooker which is too small and is scratched and worn inside of the oven - oven is greasy and not being cleaned as indicated on kitchen cleaning rota 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 19 which would benefit from further clarification as to whose responsibility this is fridge and freezer which is also rather small for the size of the home grouting around the kitchen sink and work units is stained waste bins with no lids in the kitchen area, bathroom and toilet disposable glove discarded in mop bucket outside of kitchen wall paper in the lounge is torn and needs redecorating cracked concrete patio discarded cigarette butts thrown onto garden area toilet roll holder broken in ground floor toilet extractor fan in ground floor toilet is dirty and dusty no written laundry procedures displayed no information relating to the control of substances hazardous to health (COSHH) displayed within the laundry area - laundry not lockable and contains unsecured COSHH products - ironing board stored in laundry area. A serious concern was also identified in respect of the rotary washing line. There is a rotary washing line which fixed base has been broken for the last four weeks. Staff have resorted to using the centre of a small garden table as a prop to secure the washing line. It is therefore precariously balanced and in danger of toppling over. An Immediate Requirement was issued to address this problem. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The overall outcome for this group of standards is judged to be poor. Whilst service users are supported by a stable and experienced dedicated staff group, poor staffing ratios jeopardise residents’ safety and well being. Recruitment and selection procedures need to be more robust in order to offer residents suitable protection. EVIDENCE: Five out of the ten support staff are qualified to NVQ II or above which meets the requirements of the National Minimum Standards to regards to percentage of the staff team who are qualified. As required, efforts must be made to ensure that all staff are enrolled on a vocational course. Specialist training has been provided in autism, dementia awareness, epilepsy, communication, disability and equality. Interviews with staff confirms that they are supported by management to undertake further training. Staff demonstrated a good knowledge of residents’ needs, likes and dislikes. Examination of the duty rota confirms that there are two staff per shift with one waking night staff. The manager is now supernumerary. As discussed, the manager must ensure that the duty rota is kept up to date and accurate, on one occasion an extra shift worked by the manager had not been recorded. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 21 As already stated staffing levels compromise residents’ choices with regard to activities and community outings. Serious concerns were also raised at this visit with regard to poor staffing levels which are failing to meet the complex needs of all residents. One service user is currently exhibiting increased challenging behaviours particularly at night time. The resident is also having increased nocturnal seizures. A care plan was established on 14 June 2006 states that the resident will show behaviours more when there is only one member of night staff on duty between 9 and 11 p.m. Behaviours described within the care plan include bullying staff, threatening behaviour, refusing to co-operate with night time routines and making accusations against staff. A risk assessment carried out on 5 June 2006 identifies a high level of risk to both staff and service users with regard to eight differing types of challenging behaviours exhibited by the resident Records of incidents during the last week include physical aggression towards another service user, arguing with another service user, being uncooperative towards staff, as well as other behavioural issues. There are other service users within the home who can also display challenging behaviour and who suffer from epilepsy. An Immediate Requirement was issued. Examination of a staff personnel file revealed inadequate procedures relating to recruitment and selection. The manager had failed to obtain a written reference from the last employer (although there were two other references obtained). The staff member had previously worked with children but the manager was not aware that a there is a register similar to the Protection of Vulnerable Adult (POVA) which exists for staff working with children which should have been checked (POCA). The member of staff had commenced employment on a POVAFirst check but a written risk assessment had not been undertaken to minimize the risks to residents and neither had the Commission for Social Care (CSCI) been consulted or forwarded a copy of the risk assessment. An experienced and qualified named supervisor had not been appointed who was on duty, as far as is possible, at the same time as the new employer. No formal supervision has yet taken place. It was reassuring that the employee undertook a period of induction as demonstrated on the duty rota until a satisfactory criminal record bureau disclosure (CRB) check was received. Good efforts have been made by the manager in improving training, planning and record keeping. Each member of staff now has an individual training and assessment profile and there is a central training matrix. As previously identified, induction and foundation training provided by an accredited learning disability awards framework (LDAF) provider is needed. On the whole frequency of staff supervision is also much improved, the only exception is the new member of staff. The manager states that she was awaiting the completion of the three month probationary period before 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 22 conducting a supervision session, however new staff should receive more frequent supervision. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 and 42 The overall outcome for this group of standards is judged to be adequate. The manager is resident focused and leads and supports a strong staff team. Quality assurance systems are improving so that residents and stakeholders’ views are sought and underpin the development of the service. The manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff. EVIDENCE: Mrs. Harrison was registered as manager in March 2006 and is currently nearing completion of an NVQ IV in care. She has been enrolled to commence her Registered Manager’s Award later this year. A personal development plan is required by the provider to demonstrate how she will be supported to undertake this qualification within the timescales required by the CSCI. Mrs. Harrison demonstrated through out the inspection process that she is a dedicated and caring manager. All staff who were interviewed were 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 24 complimentary about her management style and find her approachable and helpful. There are regular staff meetings and ‘thank-you’ cards from staff regarding support they had been given by the manager and staff team. Quality assurance systems are improving. Questionnaires have been sent to residents, stakeholders and relatives and there are other supplementary systems such as health and safety checks. An annual development plan now needs to be established from the information collated. The manager has been extremely proactive in securing mandatory training for staff. The majority of staff have received training in all of the required disciplines, some are also now taking refreshers. Health and safety maintenance records were sampled. These were found to be up to date with one exception, there is no certificate to confirm that a fixed electrical installation check has been undertaken in the last five years. It is also recommended that as highlighted in the recent Legionella risk assessment, that temperatures of the boiler and return water flow are routinely checked and recorded. As already mentioned, it was suggested that a lock is fitted to the laundry door as this contains unsecured COSHH products. A recent visit had been undertaken by Environmental Services – Food Hygiene inspector. A written report confirmed that there were no issues identified which is commendable. Any other items discussed during this inspection are contained within the Requirements section of this report. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 2 X X 2 X 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 26 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 4,5 Requirement To review and update the service user guide with regard to accurate details of proprietors, timescales for staff training, key contract terms (including termination). All service users must have comprehensive care plans that cover all aspects of personal, social support and healthcare needs as set out in Standard 2.3 of the National Minimum Standards and must also detail aims ands goals stating how these needs will be met – (Previous timescale of 30/9/05 is partly met). The home must be able to demonstrate that service users are involved in the compilation of their plans of care - part met, (Previous timescale of 30/9/05 is partly met). 3. YA9 13(4)(c) To continue to expand the risk management system to ensure that all areas of risk associated with individual service users are DS0000025037.V305010.R01.S.doc Timescale for action 01/11/06 2. YA6 15 01/11/06 01/11/06 46 Sedgley Road Version 5.2 Page 27 4. YA12 16(2)(n) fully assessed and documented such as incontinence, travel on the home’s transport, bathing and water temperatures. To undertake a review of activity 01/11/06 programmes to ensure that these are up to date and wholly reflect residents individual needs and preferences. To improve systems for recording and evaluating activities. To ensure that service users 01/11/06 choices from the daily menu are more consistently recorded. The home must be able to 01/11/06 demonstrate that service users preferences about how the are guided, moved and supported are complied with, and reasons for not doing so are recorded. (For example bed times and bath times, opposite and same gender care) (Previous requirement of 30/9/05 is partly met). To review the practice of hourly checks undertaken during the night for all service users. Practice must be based around service users’ preferences and individual needs - outcomes to be documented in individual care plans. To continue to progress plans to introduce a procedure for the monitoring of service users’ health with regard to potential complications such as breast, testicular and cervical cancer. Details of screening checks and monitoring (or self examination education) programmes must be included in a care plan. To discuss covert administration of medication for ‘A’ with the general practitioner and DS0000025037.V305010.R01.S.doc 5. 6. YA17 YA18 16(2)(i) 12(1) 7. YA19 12(1)(a) 01/11/06 8. YA20 13(2) 01/10/06 46 Sedgley Road Version 5.2 Page 28 pharmacist and to seek their advice and approval by 24 July 2006 – IMMEDIATE REQUIREMENT To establish a written care plan containing outcomes and guidelines for staff regarding covert administration by 28 July 2006 and to forward a copy to the CSCI by 31 July 2006. – IMMEDIATE REQUIREMENT. To discuss covert administration of medication for ‘A’ within a multi-disciplinary team and to record outcomes by 20 August 2006. IMMEDIATE REQUIREMENT. The home must improve medication administration, and record keeping with regard to the Medication Administration Record (MAR) charts. To ensure that all MAR charts are accurate and up to date with appropriate letter codes entered to confirm whether or not medicines have been administered. To ensure that detailed guidelines are established for all ‘as and when required’ (PRN) medications – for example: when precisely the medication can be administered, what the initial dose to be administered is, what the maximum daily dosage is, how long the treatment should be continued for before further advice is sought from medical practitioners. Copies must be held on individual service users’ case files or central medication folder. To ensure that drug cupboard 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 29 key is held separate from any other master keys at all times. A staff competency monitoring procedure to ensure the correct administration of medication must be developed and completed on a regular basis with records maintained. To ensure that when any changes of medication are made on the MAR sheets by staff, such as the addition of new medication, two staff initials are obtained to confirm accurate instructions have been recorded. 01/11/06 To complete repairs and redecoration of the outside of the property – (Previous requirement originally made November 2002 is not met). The stains must be removed from the carpets in the hallways. (Previous timescale of 30/11/05 is not met). Any personal items that belonged to service users that were stolen in the burglaries must be replaced by the home. (Previous timescale of 1/11/05 is not fully met). To ensure that the rotary washing line is securely fixed with a suitable base by 25 July 2006 – IMMEDIATE REQUIREMENT All of the environmental and premises issues identified in the sections of the inspection report as needing attention must be addressed, (i.e. general maintenance, décor, safety and infection control/laundry room. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 30 9. YA24 16(1) A detailed plan of action for each issue with dates for completion must be submitted to the Commission for Social Care Inspection. To ensure that staff cease throwing cigarette ends onto garden area. All staff (names supplied to CSCI) must be enrolled on a NVQ level 2 or 3. (Previous timescale of 30/11/05 is not met). 10 YA32 18(1)(c) 01/11/06 11. YA33 18(1)(a) To carry out an immediate 01/09/06 review of staffing levels at night time with a view to increasing night time support. To forward written proposals and outcomes to the Commission for Social Care Inspection by 25 July 2006. – IMMEDIATE REQUIREMENT In the interim to carry out a written risk assessment and implement control measures to minimize the risk to service users’ safety and well being at night time. To forward a copy to the Commission for Social Care Inspection by 25 July 2006. – IMMEDIATE REQUIREMENT The Manager must undertake a review of staffing ratios and service users dependency levels. Sufficient staff must be allocated on a daily basis to provide all service users with a range of stimulating activities and which meets their individual needs and preferences. To forward proposals to the Commission for Social Care Inspection. To ensure that the duty rota is kept up to date and wholly 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 31 accurate at all times. 12. YA34 19(1)(b) To improvement recruitment and selection procedures – To ensure that a written reference is obtained from the person’s last employer prior to appointment. If appointing a new member of staff on a POVAFirst check – a written risk assessment must be undertaken to minimize risks to service users. This must be discussed and forwarded to CSCI. To ensure that where persons have previously been employed in work involving children that a POCA check is undertaken. To ensure that where workers are employed on a POVAFirst check that an experienced and qualified member of staff is appointed as supervisor, who is as far as possible on duty at the same time (and this is identified on the rota). 13. YA35 18(1) The home must be able to demonstrate that staff use Learning Disability Award Framework accredited training. (Previous timescale of 30/09/05 is not met). All staff must receive at least six formal supervision sessions a year. (Previous timescale of 30/09/05 is partly met). The provider must establish and forward an individual personal development plan for the Registered manager of Sedgley DS0000025037.V305010.R01.S.doc 01/09/06 01/11/06 14. YA36 18(2) 01/11/06 15. YA37 18(1)(c) 01/09/06 46 Sedgley Road Version 5.2 Page 32 road to CSCI by 1 September 2006. 16. YA39 24 There must be an annual development plan for the home, based on a systematic cycle of planning, action and review. (Previous timescale of 30/11/05 is not met). To ensure that a electrical fixed wiring installation check has been undertaken in the last years with documented evidence obtained. To ensure that COSHH is held securely at all times in the laundry area. 30/11/06 17. YA42 13(4)(c) 01/10/06 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 YA6 Good Practice Recommendations To consider introducing different person centred planning styles (for example, essential life style planning, life story books, PATH and MAP). To provide staff with training in person centred planning. To reinstate Antecedent behavioural consequence charts for the recording and analysing of one resident’s increased challenging behaviour. That the minutes of service users meetings are expanded to record outcomes to topics raised. To consider offering more opportunities for service users to participate in the running of the Home and to contribute to the development of policies and procedures through joining staff meetings, representation in management structures, recruitment and selection of staff. 2. YA8 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 33 3. YA17 To demonstrate how residents participate in weekly menu planning. To undertake calculations of residents’ body mass index and include in nutritional care plans. To consider obtaining a Controlled Drugs Register. To undertake recorded temperature checks of the manager’s office where the drugs cupboard is located to ensure that the temperature does not exceed 25 oC on a regular basis. 3. YA20 4. YA37 3. YA42 It is recommended that the home is enabled to access and use e-mail and web site facilities to assist with communication and researching current good practice and guidance. As per recommendations in Legionella risk assessment – to carry out recorded temperature checks of the boiler and return water flow. 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 46 Sedgley Road DS0000025037.V305010.R01.S.doc Version 5.2 Page 35 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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