Inspection on 17/06/05 for 5 Wellington Street

This inspection was carried out on 17th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

5 Wellington Street 03/04/07

5 Wellington Street 26/01/06

5 Wellington Street 11/11/04

5 Wellington Street 07/06/04

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 7 Wellington Street West Bromwich West Midlands B71 1DR Lead Inspector Jayne Fisher Announced 18 May 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 7 Wellington Street Address West Bromwich, West Midlands, B71 1DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 532 3556 Pioneer Care Limited Ms Sandra Horsley Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th September 2004 Brief Description of the Service: 7 Wellington Street is a semi-detached property which is rented from the Local Authority and is located in West Bromwich. The centre of town is within a two mile radius and there are local shops nearby. Public transport is good. The Home currently provides care for two persons with learning disabilities one of whom also has a physical disability. The Home is able to provide care for service users with complex needs and challenging behaviour. The accommodation includes: a dining area, lounge, kitchen, downstairs walk in shower and toilet, three bedrooms on the first floor, a bathroom and toilet, and sleeping in room. There is a ‘Wessex’ style lift leading from the lounge area directly into one of the service user’s bedroom who has a physical disability. There is a ramp leading to the front door and back garden. There is off side parking on the road in front of the property. The garden to the rear is shared with No. 5 (which is also a care home owned by the same company). There is a patio and large lawned area which is secluded. Service users attend either Local Authority run day centres or have an in-house day care provision. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.00 a.m. and 4.30 p.m. 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: formal interviews with the manager, home leader, assistant manager and a support staff who were on duty. There was also a tour of the premises. Both residents were at home during varying stages of the inspection process. Open dialogue was not possible with residents therefore the inspector relied upon body language and observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative, the pre-inspection questionnaire, feedback from relatives and an action plan submitted by the home following the last inspection. What the service does well: Staff strive to ensure that residents are included in the running of the home and have opportunities to develop their practical life skills. For example residents can watch staff prepare their meals when in the kitchen and can lay the table, tidy up their rooms and vacuum if they wish. The activities provided for residents are varied and stimulating with lots of opportunities for going out. Residents like to go to church and are also able to receive visitors from the church in their home. Staff are very good at communicating with residents and there is a very friendly and happy atmosphere. Upon talking to staff it was evident that they are committed to raising standards and have a clear understanding of residents’ needs. Staff do not make choices on behalf of residents, instead residents are given the time and encouragement to make their preferences known. For example they can choose what they want to eat and drink, and what they wish to wear each day. Staff take care to ensure that residents personal hygiene is maintained and their clothing is modern and reflects their personalities. Residents go on holiday each year and this is funded by the organisation. They have just returned from their holiday in Spain. There is very good monitoring of health care needs so that any problems are quickly dealt with. Residents have access to a range of healthcare specialists. Staff are competent and experienced; they also benefit from managers who 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 6 are supportive and knowledgeable. There are very good training programmes for new staff. The home has appropriate procedures in place to safeguard service users from abuse. The premises are homely and comfortable. There are aids and adaptations for people using wheelchairs. Residents’ bedrooms are decorated and furnished to a high standard and match their tastes and personalities. Residents are supported by staff to maintain relationships with their families. Feedback from relatives was very positive. They are very pleased with the care and consideration that their family member is given by all of the care staff. No. 7 Wellington Street is a care home which offers a family type environment run by professional staff. The service provided is flexible and operated around residents’ preferences, needs and wants. Staff strive to ensure that residents’ rights as individuals are respected and protected. What has improved since the last inspection? What they could do better: There is a very good care planning system in place with lots of information for staff to help them in providing support to residents. Residents also have a photographic/pictorial care plan which is an aid to help them understand their how their needs will be met. The home now needs to introduce different methods to assist residents to make their preferences and aspirations known, for example through ‘essential life style planning’. Although there are lots of community based activities there needs to be more staff on duty (particularly at weekends), so that residents can make choices as to whether they want to go out together, or on their own with the support of staff. Activity programmes now need to be updated as they were first established in 2003 and now need to be reviewed. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 7 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. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 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 standard(s) 1, 3 and 5 The homes Statement of Purpose and Service User Guide are excellent providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: Since the last inspection the home has amended the Statement of Purpose as required. There is a pictorial service user guide. The contract/statement of terms and conditions of occupancy has also been amended and now contains accurate details with regard to fees charged and contains all other information as required by the National Minimum Standards. Examination of care plans and discussion with staff confirms that access to specialists is provided, for example psychology and psychiatry. Due to changes in challenging behaviour service users are being referred again to psychologists for support. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The home has a comprehensive care planning system so that service users know their assessed and changing needs and personal goals are reflected in their individual plan. Only slight expansion is needed to allow service users more opportunities for participation in care planning and thereby giving them chances for identifying their aspirations and wishes. EVIDENCE: Examination of care plans and case tracking confirms that service users’ needs are identified and met. There is a comprehensive assessment tool which is periodically reviewed. Care plans are also regularly reviewed and there is evidence that service users’ and their families are invited to attend care plan review meetings, as previously requested. There is excellent monitoring of care plan goals through a very detailed and comprehensive daily reporting system. Care plans cover all aspects of personal, social and health care needs. Care plans have been reproduced in a pictorial/photographic format for service users through a person centred planning approach. This system now requires further expansion to include an essential life style planning which will enhance the system further due to service users’ complex communication needs. It was 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 11 pleasing to note that staff have already received training in this aspect and clearly understand the concept of this approach. Service users can exhibit challenging behaviour and during interviews staff demonstrated a competent attitude to dealing with incidents which involves de-escalation techniques. Physical restraint is employed by removing the service user from the environment with their agreement although there is no direct physical intervention or force used. Debriefing and support is provided to service users in a sensitive manner by staff. Although there are detailed behavioural plans in place, these required updating with the new strategies employed by staff and identifying the differing behaviour. The home leader stated to update these immediately upon the deficiencies being pointed out. The home now uses behavioural charts and incident report forms. However, more care is needed in ensuring that all incidents are accurately recorded and reported. As discussed with management, antecedent behavioural consequence (ABC) charts may be more appropriate and would assist psychologists in helping to establish behavioural strategies. There are comprehensive and detailed risk management and assessments. Only slight expansion is necessary with regard to risk assessments and wheelchairs mainly due to new risks which have been identified by the Medicines and Healthcare Products Regulatory Agency. Information was supplied to the home on the day of the inspection. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14 and 16, Staff encourage service users to maintain and develop social, emotional, communication and independent living skills and as a result they are provided with lots of opportunities for personal development. Links with the community are good however more opportunities could be offered for service users to go out as individuals rather than in a group, which would further enrich their lives. EVIDENCE: Observations, interviews with staff and examination of documentation confirms that staff strive hard to promote ordinary living principles and social inclusion. For example it was pleasing to see that service users were involved in food preparation by being able to watch staff prepare their meals. They are also included in assisting with housework tasks. Service users are able to go to church when they wish and on Christmas day church visitors were invited to the home to give a service. As with every aspect of daily living there are excellent daily reports completed by staff which confirms that service users receive one to one support, lots of social stimulation and positive interaction sessions. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 13 Each service user has an individualized activity programme. On examination these are very detailed with time slots from 9.00 a.m. – 10.00 p.m. However, the programmes were devised in October 2003 and now require updating as some activities identified are no longer occurring. There are good links with the community with service users enjoying a wide range of community based activities. However, due to staffing levels, service users generally have to go out in pairs rather than as individuals. On occasions there are extra staff on duty in order for them to go out individually however this needs to be provided on a more regular basis. The Home must therefore review staffing levels particularly at weekends in order for these opportunities to be provided. It would also give more choice to service users, to remain at home, to go out, or to come home earlier than planned. Staff support service users to maintain family links through a variety of strategies which is commendable. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Personal support is offered in such a way as to promote service users’ privacy and dignity. The health needs of service users are well met and careful monitoring helps identify any potential complications at an early stage ensuring service users’ receive the treatment they require. EVIDENCE: During interviews staff demonstrated a proactive attitude to dealing with health care issues and accessing the appropriate support from specialists. For example, the home has recently requested that one service user receives blood screening for a possible ailment. There are excellent recording methods to identify any potential complications from testicular, breast and cervical cancer, bowel and other health related issues. The home carefully monitors eating and encourages service users to follow a healthy eating plan. There is an excellent nutritional care plan in place for one service user. Nutritional screening and assessment tools have been completed, but these now require review as they were established in October 2003. In the past the home has experienced difficulties in weighing service users and have tried to employ different strategies. For example, one service user is weighed on attendance at regular hospital appointments. Further information 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 15 has been supplied by the inspector with regard to alternative measures such as the ‘malnutrition universal screening tool’. There are excellent procedures in place with regard to pressure area care. All service users have received regular health care check ups including dental and eye tests. The home does need to pursue hearing tests as discussed. One service user’s care plan needs expansion to cover continence management. Since the last inspection the home has reviewed the medication policy and although now more comprehensive, this requires further slight expansion and clarification on some aspects. A full assessment of the control and administration of medication will be undertaken at the next inspection. Interviews with staff confirms that they pay particular attention to respecting service users’ privacy and dignity. Service users are clearly allowed to make their preferences known and enabled to make choices regarding aspects of daily living. However, unfortunately one service user is unable to choose their own clothing as this is purchased by relatives. This can create difficulties particularly as footwear should be carefully measured. The home needs to pursue opportunities for this service user to be able purchase their own clothing in order to promote dignity and individual rights. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There is a comprehensive complaints system which ensures that users’ views are listened to and acted upon. The home is making good progress in ensuring policies, procedures and practice safeguard service users from abuse. EVIDENCE: The home has a comprehensive complaints policy which has been produced in a pictorial format. The home has a copy of the Local Authority vulnerable adult abuse procedures and the Department of Health guidance on the Protection of Vulnerable Adults (POVA) scheme. They have their own vulnerable adult abuse policy however this now requires updating to include details of the new POVA scheme. Half of the staff team have received training in vulnerable adult abuse awareness and further training will be provided to the remaining staff. It was very pleasing to see that upon appointment, new staff are given a copy of the whistle blowing policy which they sign for as an agreement of their acceptance. The home has good financial procedures to safe guard service users from abuse only slight improvement is needed. Staff do not act as appointee for any service users, instead their finances are managed by family or the Local Authority. Staff do provide assistance with managing service users’ personal allowance and disability benefits. On examination there are thorough records maintained of all expenditure with receipts obtained for purchases and two staff signatures for all transactions. A random sample examined confirmed that monies balanced accurately with records maintained. However, it was identified that on one occasion a service user had had to pay for their own clinical waste bags and antiseptic wipes. The home leader confirmed that this 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 17 had been an oversight and that these items are supposed to be purchased by the home. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 29 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: There is regular redecoration and maintenance of the premises. The home has a maintenance book to record repairs which are reported to the landlord who is the Local Authority. The home is accessible for wheelchair users with ramps to the front and rear of the premises. There is a Wessex style vertical lift in the lounge which gives direct access for one service user into their bedroom. There is a range of aids and adaptations including a specialist hoist and tracking system. There is hydraulic Huntleigh bed which is serviced on annual basis according to the manufacturer’s specifications. Bedrails were found to be securely fitted. All bedrooms and furnishings are individualised and reflect service users’ personalities. Care plans contain details regarding the furniture supplied in accordance with the National Minimum Standards. There are no bedroom door locks as service users are not able to operate such devices. As a compromise the home needs to include this information in their statement of purpose. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 19 There is a large garden to the rear which has recently been fenced off from the adjoining property which is another care establishment run by the same service provider. This affords greater privacy. There are only a couple of minor works identified as contained within the Requirements section of this report. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. There is a competent staff group offering consistency of care for service users. The induction of new staff is good with staff demonstrating a clear understanding of their roles. EVIDENCE: Observations and interviews demonstrated that key workers have in depth knowledge regarding service users’ needs. Job descriptions have been reviewed as previously requested. However these are combined for staff who work in the care home and also other staff who work in domiciliary care. As a result some tasks (such as assisting service users to change light bulbs) are not entirely appropriate and therefore separate documents are required. The home is making good progress in providing vocational training for staff. Out of the eight staff employed, 2 have completed NVQ training and 3 staff are currently undertaking an NVQ course. Training in challenging behaviour has been provided although due to staff changes this now needs to be provided again for at least 5 staff. Examination of the duty rota confirms that there has been no reduction in staffing levels despite a reduction in the number of service users currently accommodated. There are two staff on duty per shift. However, as already 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 21 stated in this report a review of staffing levels needs to be undertaken to provide more choice for community outings. There are detailed records and certificates with regard to staff training. All new staff receive induction and foundation training which is provided by an accredited learning disability awards framework provider. There is also an inhouse induction programme. Examination of a personnel file for a newly appointed member of staff confirmed that there is a robust recruitment and selection procedure which safeguards service users from abuse. Terms and conditions of employment were not on staff files although the manager states that these have been distributed to staff and are awaiting collation. There is an excellent appraisal system for staff. The frequency of staff supervision sessions is improving although further progress is necessary. There are detailed supervision records which demonstrate a proactive and supportive leadership style operated by senior staff. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 and 43 The manager is supported well by her senior staff in providing clear leadership through out the home with all staff demonstrating an awareness of their roles and responsibilities thereby protecting service users’ rights and interests. EVIDENCE: The Registered Manager for No. 7 Wellington Street also manages a number of other services. The manager has been working for the organisation for a considerable period and regularly updates her knowledge through attending training courses. Interviews demonstrated she has a clear understanding of legislation and best practice. She cascades her knowledge to staff who are also experienced and knowledgeable. There are good support mechanisms in place for staff. Examination of staff personnel files confirmed appropriate pre-employment checks are undertaken and records maintained. There was only one exception where a new member of staff had not yet provided forms of identification. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 23 There is a strong commitment towards staff training. Mandatory training is given high priority. Some training now requires updating as there have been changes in the staff team. The majority of staff have received training in moving and handling, first aid awareness, food hygiene and infection control. 50 of staff have undertaken training in health and safety and fire safety training. 2 staff need their fire training to be up dated and 2 other new staff have not yet received fire training which must be given priority. Good progress is being made to progressing the quality assurance system. The home has established questionnaires for feedback from stake holders in the community. They are currently arranging for staff questionnaires to be included as part of this process. The health, safety and welfare of service users are promoted and protected. For example, there is good accident reporting systems. All maintenance and service checks are up to date on random sampling and according to information supplied on the pre-inspection questionnaire. Only a couple of minor improvements are necessary with regard to ensuring that maintenance checks on wheelchairs and bedrails are recorded. The home still needs to ensure that the names of staff participating in fire safety drills are fully recorded. There are regular visits by the owner’s representative. However, not all copies of monthly visits were available (for example, February and April 2004). These reports had also not been forwarded to the Commission for Social Care Inspection as required. Information which is supplied on monthly reports needs greater detail in order to fully comply with the Care Homes Regulations 2001, Regulation 26 and in order to be able to form an opinion of the standard of care provided. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 3 3 x Standard No 11 12 13 14 15 16 17 3 3 2 2 3 3 x Standard No 31 32 33 34 35 36 Score 2 2 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Wellington Street Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 2 2 2 E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 25 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 6 Regulation 15 Requirement To ensure behavioural care plans are kept up to date and identify any new strategies for deescalation. To ensure that behavioural charts and incident report forms are more accurately completed. To further progress person centred planning with essential life style planning, life story books etc. To review and expand risk assessments for wheelchair users identifying risk associated with using posture belts and manufacturers specifications with regard to maintenance checks and servicing. To review and update indivdiualized activity programmes to identify and reflect service users preferences and needs. To provide more opportunities for service users to undertake community based activities on an individual basis. To undertake a review of staffing levels to ensure they are Timescale for action 1/10/05 2. 9 13(4)(c) 1/7/05 3. 12 12(1)(a) 1/10/05 4. 13 16(2)(m) 1/8/05 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 26 5. 6. 18 19 12(3) 12(1)(a) sufficient to undertake these tasks. To pursue efforts to ensure service users are supported to choose their own clothing. To make the following improvements with regard to healthcare monitoring and recording: 1) To ensure that service users receive regular eye tests, dental checks and hearing tests. (Previous timescale of 1/7/04 is partly met). 2) To introduce a formal procedure with regard to observational weight checks. (Previous timescale of 1/7/04 is partly met). 3) To ensure care plans contain up to date details with regard to continence management. (Previous timescale of 1/7/04 is partly met). 4) To review and update nutritional screening and assessment tools. 1/9/05 1/9/05 7. 20 13(2) 1) To review and expand medication policy using guidelines issued by the British Pharmaceutical Society, June 2003. (Previous timescale of 1/4/04 is partly met). 2) To ensure copies of reports following pharmacists visits are obtained. (Previous timescale of 1/4/04 is not met). 3) To continue to progress plans for ensuring all staff receive accredited training in the safe handling of medication. 1/10/05 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 27 (Previous timescale of 1/4/04 is partly met). 4) To consult with pharmacist to request that regular as and when required (PRN) treatment is included on computerized medication administration record (MAR) sheets. 5) To ensure that any handwritten instructions on MAR sheets are signed and witnessed by two members of staff to confirm accuracy. To review and update the 1/9/05 vulnerable adult abuse procedure to ensure that it contains details of new Protection of Vulnerable Adults (POVA) scheme. To continue to progress training for all staff in vulnerable adult abuse. To improve financial procedures by ensuring that service users are not charged for items which should be included as part of their basic contract fee such as clinical waste bags and cleasing wipes. 9. 24 23(2)(b) The Home must ensure that bathrooms are suitable for service users’ specialist needs. For example the proposed conversion of the walk in shower must take place as soon as possible, in order to allow for one service user to be able to access the shower. (Previous timescale of 1/5/03 is partly met). To securely fix wardrobes to bedroom walls. (Previous 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 28 8. 23 13(6) 1/9/05 timescale of 1/1/05 is not met). To ensure that bedrails are checked on a regular basis to ensure that they are securely fixed with records maintained. (Previous timescale of 1/1/05 is partly met). To replace stained carpet on the landing. To review support workers job descriptions to ensure that these reflect the roles and responsibilities of care home staff as opposed to domicillary support workers. Reference must be made to the code of conduct set by the General Social Care Council. To ensure that 50 of the care staff team are qualified to NVQ 11 or above by 2005. To pursue plans to ensure that all staff receive training in managing challenging behaviour including breakaway techniques. To ensure that all staff receive regular recorded supervision (at least six times per annum). (Previous timescale of 1/1/05 is partly met). To ensure that the Registered Manager is qualified to NVQ 1V in care and management by 2005. To provide evidence that the quality assurance system includes feedback from stakeholders including doctors, district nurses and other professionals, as well as families and relatives. (Previous timescale of 1/1/05 is partly met). To obtain and hold information and documents in respect of 10. 31 18(1)(a) 1/10/05 11. 32 18(1)(c) 1/10/05 12. 36 18(2) 1/10/05 13. 37 18(1)(a) 31/12/05 14. 39 24 1/10/05 15. 41 17(2) 1/9/05 Page 29 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 16. 42 23(2)(e) persons carrying on, managing or working at a care home as listed in Schedule 4 of the Care Home Regulations 2001. (Previous timescale of 1/4/04 is partly met). To ensure that records of fire drills include the names of staff who have participated in the drill. All staff must participate in at least two fire safety drills per annum. (Previous timescale of 1/12/04 is not met). To ensure that wheelchair maintenance checks undertaken by the home are fully recorded. To progress plans to ensure that all staff receive training in: 1) to ensure that all staff receive a minimum of two fire safety training sessions per annum. (Previous timescale of 1/12/04 is partly met). 1/8/05 17. 42 18(1)(a) 1/10/05 18. 43 17(2) 26(4) 2) health and safety awareness. To ensure that the business plan is individualized to reflect the service provided by the home as well as being a corporate document. To ensure that copies of the monthly reports from visits undertaken by the Owners representative are available on the premises and a copy forwarded to the Commission for Social Care Inspection. To ensure that the reports contains information in sufficient detail as requried by the Care Homes Regulations. 1/9/04 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 30 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. 2. 3. Refer to Standard 6 23 Good Practice Recommendations To consider introducing antecedent behavioural consequence (ABC) charts. To consult with insurers to seek confirmation as to the total sum of service users monies which may be held on the premises at any one time. 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 31 Commission for Social Care Inspection Mucklow Office Park, West Point 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 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 32 7 Wellington Street E55 S4774 7 Wellington Street V227364 180505 Stg4.doc Version 1.30 Page 33 - 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!